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Health Disparities Collaboratives Diabetes Changing Practice Changing Lives Diabetes Contents Acknowledgments .................................................................................................... 2 The Challenge........................................................................................................... 4 The Solution ............................................................................................................. 6 Care Model Checklist............................................................................................... 7 Self-Management ............................................................................................... 8 Decision Support ............................................................................................. 15 Clinical Information System............................................................................. 23 Delivery System Design.................................................................................... 35 Organization of Health Care .......................................................................... 41 © 2002, Diabetes 1.0 Produced by: Institute for Healthcare Improvement Community...................................................................................................... 49 In partnership with: National Association of Community Health Centers Care Model: Changes for Specific Populations ....................................................... 58 Improving Chronic Illness Care, a national program of The Robert Wood Johnson Foundation Improvement Model............................................................................................... 61 Centers for Disease Control and Prevention, Division of Diabetes Translation Aims ................................................................................................................ 62 Substance Abuse and Mental Health Services Administration Measures.......................................................................................................... 64 State Diabetes Control Program Changes ........................................................................................................... 69 National Diabetes Education Program Bayer Corporation Bibliography........................................................................................................... 70 List of Tools and Resources.................................................................................... 73 With support from: Health Resources and Services Administration, Bureau of Primary Health Care DIABETES TRAINING MANUAL 1 Acknowledgments Thanks to the Cluster Directors for their expert review of this material — and for their dedication to the health centers they guide so skillfully. Heidi Child, RN, MSN Pacific West Cluster Collaborative Director Program Director California Primary Care Association Sossity Fair, MPH, CHES West Central Cluster Collaborative Director Texas Association of Community Health Centers Tracy Jacobs, RN Mountain Plains Clinical Network Collaborative Director Community Health Association of Mountain/Plains States Julie Koppert, RNC, BSN, CDE Thanks to the hundreds of health centers that have taken part in the Diabetes Collaboratives. They led the way in testing and implementing a new approach to the care of people with diabetes, and their impressive results have inspired many more to join the effort. In particular, thanks to the following individuals who helped develop this manual by sharing what they learned in the course of applying the Care Model to improving diabetes care and to all those who gave their time and good ideas to the development of this resource. Mary Jo Bloominger, MPAS Susie Cook Physician Assistant, Diabetes Team Leader Community Health Care Clinical Director Columbus Neighborhood Health Center, Inc. Katie Bogart, MSW Denice Cora-Bramble, MD Project Manager Institute for Healthcare Improvement Senior Medical Advisor Health Resources and Services Administration Bureau of Primary Health Care Katherine Brieger, RD, CDE Vice President – Community Initiatives Hudson River Healthcare Midwest Cluster Collaborative Director Michigan Primary Care Organization/Midwest Clinicians’ Network Penny Carver, MEd Wanda Montalvo, RN, MSN, ANP Mady Chalk, PhD Northeast Collaborative Director Connecticut Primary Care Association Janice Wilkerson, RN, CPHQ Quality Management Consultant, Southeast Cluster Collaborative Director South Carolina Primary Health Care Association Senior Vice President Institute for Healthcare Improvement Connie Davis, MN, ARNP Associate Director for Clinical Improvement Improving Chronic Illness Care Paula Devitt, RN, CDE Director of Health Education La Familia Medical/Dental Center Director Office of Managed Care Center for Substance Abuse Treatment Maxine Henderson, RN Roger Chaufournier Lisa Homer, RN President & CEO Patient Information Systems Patient Care Coordinator Mountainlands Community Health Center Cynthia Clark, MA Cindy Hupke, RN, BS, MBA Program Consultant Division of Diabetes Translation Centers for Disease Control & Prevention IHI National Collaborative Director Bureau of Primary Health Care Health Disparities Collaboratives Quality Improvement Director Family Healthcare Center DIABETES TRAINING MANUAL 2 Alvin Jackson, MD John Pierson Barbara Smith, MSN, RN, CS Medical Director Community Health Services NE Cluster IS Director Connecticut Primary Care Association Family Nurse Practitioner Union-Granger Primary Care Matt Kanaracus and Karen LeDuc Lynn Price, MSN, MPH, VD Molly Soeby, MT, SC Designers Codesign Director, Patient Services Program Development Coordinator Altru Health System Lloyd Provost, MS Jane Kelly, MD Medical Epidemiologist Centers for Disease Control and Prevention Statistician Associates in Process Improvement Kathleen Reims, MD Jane Landon, RN, MS Quality Improvement Coordinator Columbus Neighborhood Health Center, Inc. Medical Director People’s Clinic Statistician Associates in Process Improvement CEO Stewart Webster Rural HC, Inc. Director, Health Disparities Collaboratives Bureau of Primary Health Care Charmaine Trujillo, RN Veronica Richardson, RN, MSN Elizabeth Magenheimer, MSN, APRN, CNM, FNP, CDE Chief, Clinical Branch/Division of Community & Migrant Health Health Resources & Services Administration Bureau of Primary Health Care Tricia L. Trinite, NP, MSPH Sarah C. Richardson Jerry Langley, MS David M. Stevens, MD Director of Chronic Disease Management Grace Hill Neighborhood Health Center, Inc. Operations Director, Internal Medicine Mountain Park Health Center Alan Tso, MD Fair Haven Community Health Center Jane Roessner, PhD Chinatown Health Clinic Writer Institute for Healthcare Improvement Frank Vinicor, MD, MPH Todd Ruppar, RN, BSN Director, Division of Diabetes Translation Centers for Disease Control and Prevention Community Health Nurse Family Care Health Centers Arcadio Viveros Ardyce Saunders-Ridolfo, RN Executive Director Salud Para La Gente, Inc. Wendy Melendrez, ARRT Health Disparities Collaborative Coordinator National Health Care for the Homeless Tammy Walker Quality Improvement Coordinator Ben Archer Health Center Marie Schall, MA Teaching and Educational Specialist Prospect Associates Theresa Mendez Collaborative Director Institute for Healthcare Improvement Doris Walzak, MD Diabetes Coordinator Mariposa Community Health Center Cory Sevin, RN, MSN Clinical Director Columbus Neighborhood Health Center, Inc. Regina Olasin, DO, FACP Vice President Clinica Campesina Vivian Whitely, RN, CDFS Medical Director Laurel Health System Charles W. Shafer, MD Clinical Coordinator Stewart Webster Rural HC, Inc. John McFarland, DDS President National Network for Oral Health Access Kathy McNamara Assistant Director of Clinical Affairs National Association of Community Health Centers Clinical Director Sioux River Valley Community Health Center DIABETES TRAINING MANUAL 3 Diabetes The Challenge Diabetes is a complex, serious, and increasingly common disease. It is the most frequent cause of blindness among working-age adults; the leading cause of nontraumatic lower extremity amputation and end-stage renal disease; and a principal cause of congenital malformations, perinatal mortality, premature mortality, and disability. Persons with diabetes are at increased risk for stroke, ischemic heart disease, peripheral vascular disease, and neuropathy. < 4% 4 – 6% > 6% The Increasing Prevalence of Diabetes Among Adults 1990 1993–1994 Diabetes is a costly disease—not only in terms of the economic burden it imposes on society, but also in terms of the human suffering imposed by the disease and its complications. Moreover, the burden of diabetes and its complications disproportionately affects minority populations and the elderly, and is likely to increase as minority populations grow and the U.S. population ages. Thus, diabetes poses an enormous public health challenge in America. 1999 Source: CDC DIABETES TRAINING MANUAL 4 Diabetes: The Challenge (continued) Diabetes: The Facts ➤ 15.7 million people have diabetes: 10.3 million diagnosed (= a sixfold increase over the past 40 years) 5.4 million undiagnosed ➤ 798,000 new cases diagnosed per year ➤ 7th leading cause of death in the U.S. ➤ Cost (United States, 1997): Total costs: $98 billion Direct medical costs: $44 billion Indirect costs: $54 billion (disability, work loss, premature mortality) Diabetes Disproportionately Affects Minority Populations ➤ African Americans African Americans are 1.7 times more likely to have Type 2 diabetes than the general population. An estimated 2.3 million African Americans, or 10.8%, have diabetes. 25% of African Americans between the ages of 65 and 74 have diabetes, and one in four African American women over 55 has diabetes. ➤ Latinos Latinos are almost twice as likely to have Type 2 diabetes. For example, diabetes affects 1.2 million or 10.6% of the Mexican American population. ➤ Native Americans Overall prevalence of Type 2 diabetes in Native Americans is 12.2%, compared to 5.2% of the general population. In some tribes, 50% of the population has diabetes. Complications of Diabetes ➤ Blindness Diabetes is the leading cause of new cases of blindness in adults ages 20 to 74 years. ➤ Kidney failure Diabetes is the leading cause of end-stage (chronic, irreversible) kidney disease. ➤ Amputations Diabetes is the leading cause of lowerextremity amputations not related to injury. ➤ Cardiovascular disease People with diabetes are 2 to 4 times more likely to develop heart disease or stroke than people without diabetes. Sources ➤ American Diabetes Association (ADA) website: www.diabetes.org/ADA/facts.asp ➤ “Diabetes: A Serious Public Health Problem. At-a-Glance 2000.” Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. DIABETES TRAINING MANUAL 5 Diabetes The Solution Although the challenge is formidable, we do know what good diabetes care looks like and we are continually increasing our knowledge about good diabetes care. The scientific literature, centers of excellence in diabetes care, and the experience of hundreds of health centers are consistent in pointing to common themes in excellent diabetes care—themes that are applicable to a wide range of chronic diseases. The Care Model outlines all of the key elements of a system of excellent care for people with chronic illness. Hundreds of health centers have already begun putting such a system of care in place, and they have begun to see significant improvement in the health of those they serve, often within a matter of months. “You actually have the opportunity to demonstrate best practice models and as a result, you can present this to companies, industries, and legislators to show that this actually works.” Janice Bacon, MD G.A. Carmichael Family Health Center Canton, Mississippi “The quality of care, the follow-up, the educational processes involved with this program, there’s nothing that’s going to replace that and most important is the clients’ involvement in their care. When you get someone to buy into helping manage their own care it really has a more significant outcome in terms of how dedicated they’ll be to following through on the program. If they know they have a good support system, of course they can do this. It would be foolhardy not to try.” Gladys Johnson Diabetes Patient Lafayette, Colorado The people who work in the health centers— senior leaders, physicians, nurses, front-line staff—and the people they serve describe the benefits best: “I’m very encouraged how a community health center with relatively limited resources can show such great improvement in our patient outcomes.” Eric Boysen, MD Clinica Campesina Lafayette, Colorado DIABETES TRAINING MANUAL 6 Diabetes Care Model Checklist Self-Management (pages 8 –14) Decision Support (pages 15–22) Use diabetes selfmanagement tools that are based on evidence of effectiveness. Embed evidencebased guidelines in the care delivery system. Set and document self-management goals collaboratively with patients. Train providers on how to help patients with self-management goals. Follow up and monitor self-management goals. Use group visits to support self-management. Tap community resources to achieve selfmanagement goals. Establish linkages with key specialists to assure that primary care providers have access to expert support. Provide skill-oriented interactive training programs for all staff in support of chronic illness improvement. Educate patients about guidelines. Clinical Information System (pages 23–34) Establish a registry. Develop processes for use of the registry, including designating personnel to enter data, assure data integrity, and maintain the registry. Use the registry to generate reminders and care-planning tools for individual patients. Use the registry to provide feedback to care team and leaders. Delivery System Design (pages 35– 40) Organization of Health Care (pages 41– 48) Community (pages 49–57) Use the registry to proactively review care and plan visits. Make improving chronic care a part of the organization’s vision, mission, goals, performance improvement, and business plans. Establish linkages with organizations to develop support programs and policies. Assign roles, duties, and tasks for planned visits to a multidisciplinary care team. Use cross-training to expand staff capability. Use planned visits in individual and group settings. Make designated staff responsible for followup by various methods, including outreach workers, telephone calls, and home visits. Use promotoras and community health worker programs for outreach. Make sure senior leaders and staff visibly support and promote the effort to improve chronic care. Assign day-to-day leadership for continued clinical improvement. Integrate Collaborative models into the Quality Improvement program. Link to community resources for defrayed medication costs, education, and materials. Encourage participation in community education classes and support groups. Raise community awareness through networking, outreach, and education. Provide a list of community resources to patients, families, and staff. DIABETES TRAINING MANUAL 7 Self-Management Patients with diabetes need support, as well as information, to become effective managers of their own health. In order to meet these needs, it is essential for them to have the following: • Basic information about diabetes • Understanding of and assistance with self-management skill building • Ongoing support from members of the practice team, family, friends, and community Providers need to be sensitive to the role that families, caregivers, and communities play in different cultures. Better patient outcomes are achieved through use of evidence-based techniques that emphasize patient activation or empowerment, collaborative goal setting, and problem-solving skills. The provider team can use standardized assessments of patient self-management needs and activities to enhance its ability to support patients. These assessments include questions about self-management knowledge, skills, confidence, supports, and barriers. Changes for Improving Self-Management ➤ Use diabetes self-management tools that are based on evidence of effectiveness. ➤ Set and document self-management goals collaboratively with patients. ➤ Train providers on how to help patients with self-management goals. ➤ Follow up and monitor self-management goals. ➤ Use group visits to support self-management. ➤ Tap community resources to achieve self-management goals. (See Community.) CASE STUDY Community Health Care Davenport, Iowa At the end of April 2000, a Physician Assistant (PA) saw a patient at a Salvation Army Adult Rehab Center, who presented with a blister on his left great toe. Two weeks later, when the blister turned into an ulcer, he was diagnosed with Type 2 Diabetes. On May 11, his HbA1c was 13.6. The PA spent a lot of time educating the man about diabetes, diet, and exercise. The patient also met with the dietician. Even after all this, he still did not seem to understand the importance of diet and exercise in controlling his diabetes: he presented for follow-up with very high blood sugar, as a result of just having eaten ice cream and cookies! The PA encouraged him to attend a Diabetes Group Visit on June 16. After the education and group discussion, he finally understood the connection between his foot ulcer, his diabetes, and self-management of his diet and exercise plan. Since then, he has been actively involved in setting goals for himself in collaboration with the health care team. The patient now returns for follow-up regularly. His blood sugars have greatly improved. On August 31, 2000, his HbA1c was 6.7, and on December 8 of that year it was 6.5. He remains at the Salvation Army Adult Rehab Center, and is making smart choices about the food he eats. He no longer chooses cookies and ice cream as a snack! DIABETES TRAINING MANUAL 8 Self-Management ➤Use diabetes self-management tools that are based on evidence of effectiveness. Steps 1 2 Tools and Resources Identify high-quality patient education materials. Review materials for reading level and cultural appropriateness. Determine if different versions — languages, literacy levels — are necessary to serve patients. 3 Review materials with the care team. 4 Test materials with a few patients and revise as necessary. 5 Make materials available to patients, families, and providers by placing them in examining rooms and waiting rooms. 6 Tips Be selective and keep materials brief. Include materials with larger print. American Diabetes Association www.diabetes.org State-Based Diabetes Control Program www.cdc.gov/diabetes/states/index.htm Work with lay health promotoras in the community to select and review materials. American Association of Diabetes Educators www.aadenet.org National Diabetes Education Program www.cdc.gov/diabetes/projects/ndeps.htm Stoplight Tool for HbA1c and Blood Sugar Targets Take Charge of Your Diabetes, for Patients www.cdc.gov/diabetes/pubs/pdf/tctd.pdf Remove outdated educational materials from the clinic. Coordinate patient education with the center’s care guidelines. Share materials with pharmacies, faith-based organizations, and community groups. Tools and Resources Icons Web link Form/Tool that may be accessed on www.healthdisparities.net Book or periodical reference Form/Tool that may be accessed via a web link to another site Phone reference DIABETES TRAINING MANUAL 9 Self-Management ➤Set and document self-management goals collaboratively with patients. Steps 1 Identify self-management tools, including the following: • An action plan that includes goals and describes behavior (e.g., increasing activity by walking 15 minutes 3 times per week) • A review of the patient’s personal barriers (e.g., too busy to exercise) • Steps to overcome barriers • The patient’s confidence level (e.g., on a scale of 1 to 10, how confident are you that you can meet your goals?) • A follow-up plan 2 Review the tool with the multidisciplinary team, including all those who will be involved in its use—physicians, nurses, volunteers, promotoras, etc. 3 Test the tool with a few patients and revise as indicated. Retest with additional patients and different populations. Tools and Resources Self-Management Support Tool Diabetes Self-Management Goal Setting (English and Spanish) Diabetes Goal Contract (English and Spanish) Dental Self-Management Tool Turning Patient Education into Self-Management, Training Instructions for Providers Chronic Disease Self-Management Program (CDSMP) www.stanford.edu/group/perc/cdsmp.html Tips Make sure staff are comfortable with the self-management philosophy and trained in behavioral techniques to support patients. Train lay workers to set goals with patients. Create a system to communicate goal changes with other providers caring for patients (pharmacy, nursing, lay community workers, etc.) so that they can reinforce them. For example, write new goals (e.g., “walk 15 minutes 3 times per week”) on a prescription pad and give to patients to show to other providers. Develop a process and train providers so that the self-management process can fit in the 15- to 20-minute visit, if necessary. It does not require a long session. Work with patients to define goals. Don’t prescribe goals or use checklists. Include family and caregivers in setting goals. Use groups for patient goal setting. 4 Establish and/or review goals with patients as part of the planned visit and follow-up. 5 Assess patients’ skill, understanding, and confidence in managing their disease. 6 Give patients a copy of goals, and place a copy in the chart. Diabetes Patient Questionnaire Have medical assistants ask patients about goals when taking vitals. Have providers review goals with patients briefly. Assign staff to arrange follow-up with patients. Document goal setting in the registry. Include some specifics of the goal and the date(s). DIABETES TRAINING MANUAL 10 Self-Management ➤Train providers and other key staff on how to help patients with self-management goals. Steps 1 Select a self-management curriculum that has been tested and found effective. 2 Train everyone on the health care team (including volunteers and promotoras) using a skilled trainer, if possible. Tools and Resources Article on a motivational intervention to improve care in Type 2 diabetes fampract.oupjournals.org/cgi/reprint/15/3/229.pdf Bayer Institute for Health Care, Patient Communication Training www.bayerinstitute.org Health Professional Training and Patient Education in Diabetes (University of Michigan Diabetes Education Center) Tips The best self-management approaches are those that are patient-oriented and assist patients with the disease as they live with it, as opposed to “shoving information at them” from a curriculum. This is a change from previous practice around diabetes education. Make training as interactive as possible. Include role-play and case studies. Have “homework” and in-class assignments. www.med.umich.edu/mdrtc 3 4 5 Define tasks and roles—e.g., who will set the action plan, who will do follow-up, who will fill out the assessment form—and assign them. Self-Management Checklist (to Enhance Your Self-Management) Self-Management Coordination Matrix Let self-management coaches self-select. Those who are comfortable with the self-management approach are the most effective coaches. Test the self-management tool with one provider and team working with several patients. Start on a small scale. Provide follow-up education for providers. Review the self-management tool and gradually add layers of competence and complexity. Educate providers about the importance of not “lecturing” their patients. Let patient concerns lead discussions. Think incrementally about behavior change. Encourage patients to take small steps and build confidence through success. DIABETES TRAINING MANUAL 11 Self-Management ➤Follow up and monitor self-management goals. Steps 1 Train staff for follow-up. 2 Test having different staff or volunteers do follow-up. 3 Schedule follow-up based on dates in the action plan. 4 Test follow-up mechanisms (calendar, registry, tickler file) and scripts. 5 Include problem solving (a technique to help patients identify problems and develop solutions) in follow-up. Tools and Resources Tips Don’t skip follow-up; patients will think you don’t care. Make sure patients determine the follow-up date and method. Follow-up can be by phone, email, fax, home visit, clinic visit, etc. Use trained, culturally competent lay people for follow-up. Chronic Disease Self-Management Program (CDSMP) www.stanford.edu/group/perc/cdsmp.html DIABETES TRAINING MANUAL 12 Self-Management ➤Use group visits to support self-management. Steps Tools and Resources 1 Identify the type of group visit (support group, educational group, etc.). Turning Patient Education into Self-Management, Train-the-Trainer Instructions for Providers 2 Identify a group to focus on (e.g., Hispanic population, homeless, newly diagnosed). Group Visit Agenda Tips Assess cultural/ethnic needs and identify appropriate methods/materials for patient education. Don’t confuse this type of group with a group visit that includes the physician and medical care (described in Delivery System Design). Let the group determine the content of sessions. Leaders can monitor the content to assure that critical information is covered. 3 Identify and train the facilitator. 4 Take care of logistics (space, staffing needs, billing requirements). Contact health centers that have been conducting group visits for “lessons learned” about logistics of scheduling, rooms, etc. 5 Publicize group visits through an appropriate communication channel. Make reminder calls. Provide a meal. Use lay leaders. Anticipate patient’s need for transportation and child care. DIABETES TRAINING MANUAL 13 Self-Management ➤Tap community resources to achieve self-management goals. (See Community.) Steps 1 Tools and Resources Identify resources in the community that would help in meeting self-management goals, such as exercise programs and meal programs. Tips Consider senior centers, faith-based organizations, and public housing. Draw on the community network. Think big: local, state, federal. 2 Educate patients and staff on local resources. See list of tools in Community section. Provide resource list to clients. DIABETES TRAINING MANUAL 14 Decision Support Effective chronic illness management programs follow explicit guidelines or protocols, preferably evidence-based guidelines. Reminders, provider education, appropriate input, collaborative support from relevant medical specialties, and patient participation support their implementation. Changes for Improving Decision Support ➤ Embed evidence-based guidelines in the care delivery system. ➤ Establish linkages with key specialists to assure that primary care providers have access to expert support. ➤ Provide skill-oriented interactive training programs for all staff in support of chronic illness improvement. ➤ Educate patients about guidelines. (See Self-Management.) CASE STUDY Johnson County Community Health Care Systems Wrightsville, Georgia Community Health Care Systems is a small, rural health center serving a low-literacy population. The providers received training on the use of the latest evidence-based guidelines. They used the guidelines to create a protocol format and a flow sheet that serves as a checklist reminder system for comprehensive diabetes care. Perhaps the most important “prompt” the providers have created is the patients who come to them. The patients have been educated in the guidelines through diabetes education displays placed in the waiting room, a diabetes bulletin board in the examining room, and efforts and education to have the patients “Take Control” of their diabetes. The providers now have a number of prompts to follow the guidelines: the education they receive on a regular basis, the flow sheet that serves as a reminder and, most important, the well-informed, activated patients who are enthusiastic, informed participants in their own care. DIABETES TRAINING MANUAL 15 Decision Support ➤Embed evidence-based guidelines in the care delivery system. 1 Steps Tools and Resources Tips Identify existing guidelines. Websites with information on evidencebased medicine: Don’t reinvent the wheel! Obtain existing guidelines from the National Guideline Clearinghouse or your state Diabetes Control Program, or use standards from reputable organizations such as the American Diabetes Association (ADA). Examples: • Glycemic control for people with diabetes: HbA1c (%) goal <7 • Lab evaluation of GHb: quarterly if treatment changes or patient is not meeting goals; or two times a year if the patient is stable The Unit for Evidence-Based Practice and Policy www.ucl.ac.uk/openlearning/uebpp/uebpp.htm Centre for Evidence-Based Medicine cebm.jr2.ox.ac.uk Netting the Evidence www.shef.ac.uk/~scharr/ir/netting New Zealand Guidelines Group www.nzgg.org.nz National Guideline Clearinghouse Involve a provider champion or your Medical Director in selecting guidelines, but be certain to obtain consensus on guidelines among the providers you expect to implement them. Focus initial effort on guidelines that are easily agreed upon. Don’t get sidetracked by controversial topics: work on those guidelines later. Mix and match guidelines as needed. www.guideline.gov Cochrane Reviews www.cochrane.org/cochrane/revabstr/ mainindex.htm Trip Database www.tripdatabase.com Clinical Evidence for Providers [email protected] or 877-485-8074 Tools and Resources Icons Web link Form/Tool that may be accessed on www.healthdisparities.net Book or periodical reference Form/Tool that may be accessed via a web link to another site Phone reference DIABETES TRAINING MANUAL 16 Decision Support ➤Embed evidence-based guidelines in the care delivery system. (continued) Steps 2 Review guidelines and select the best one(s) for your clinical setting. Make sure they are based on the best medical evidence. 3 Teach providers the basics of evidence-based medicine and guideline review. 4 Have providers review and discuss guidelines to develop consensus. Tools and Resources Evaluating a Guideline Tips Set clear expectations and timelines for guideline development, review, and adoption. If committee review is required for accepting a guideline, have the committee consider only the evidence-based guideline. Include evidence summaries that accompany good guidelines to facilitate discussion. Send a physician to a CME session on evidence-based medicine. To get buy-in from influential naysayers, involve them in the process. Remove barriers to guideline implementation, such as unavailability of needed vaccines, slow turnaround time for lab results, inertia. 5 Customize guidelines for the clinic, within the boundaries of the evidence. 6 Use a standardized assessment to diagnose and determine disease control and risk for complications (heart, eyes, kidneys, etc.) to guide management for all patients. 7 Consider conducting a baseline chart audit to benchmark your current practice against agreed-upon guidelines. Agree before the audit which patients to include (see Clinical Information System for establishing a registry). Do NOT omit charts because a randomly selected chart is not that of a “typical” patient. Don’t get mired down in complex algorithms or standards of care. Talk to other clinics that have already customized guidelines to get the fastest process in place. Keep chart abstraction simple and quick; collect only the data that are needed. Diabetes Care Chart Audit Have providers abstract a random sample of their own charts. This helps them discover the gap between what they know is good practice and what they actually do. Try a “lunch and learn” session to achieve this. Try to integrate the chart audit with development of the registry. Talk to other clinics that have already customized guidelines. DIABETES TRAINING MANUAL 17 Decision Support ➤Embed evidence-based guidelines in the care delivery system. (continued) Steps 8 9 Use flow sheets, pathways, or checklists to embed guidelines into daily practice. The guidelines include triggers for care. Link guidelines to the information system to provide prompts. Tools and Resources Diabetes Flow Sheet Patient Encounter Form Diabetes Protocol Checklist Tips The patient encounter form may also be known as a visit note, flow sheet, treatment planning form, order entry form, etc. Make it as hard as possible to ignore the guideline. Make it easier to do the right thing (e.g., check a box instead of having to write out a lot of information). Make it efficient to follow guidelines. Physicians will be more likely to use them if they save time. Make it hard to forget to follow guidelines: work with the lab to develop staged testing protocols (e.g., automatic microalbumin measurement when an annual screening U/A is negative for protein to avoid recall of patient/resubmission of urine). Ask teams that are already practicing evidencebased medicine to spread the word. If a team is not practicing this way, have them visit another clinic that is. 10 Review and update guidelines for care regularly (at least yearly). Why Don’t Physicians Follow Clinical Practice Guidelines? A Framework for Improvement 11 Remove barriers identified with previous guidelines. Michael D. Cabana; Cynthia S. Rand; Neil R. Powe; Albert W. Wu; Modena H. Wilson; Paul-André C. Abboud; Haya R. Rubin. JAMA. 1999;282:1458-1465. Think about why guideline implementation is not working: • Lack of awareness • Lack of agreement • External factors (time, money, resource availability) • Inertia Discuss which of these factors is playing a role. You may have to address multiple issues simultaneously. DIABETES TRAINING MANUAL 18 Decision Support ➤Establish linkages with key specialists to assure that primary care providers have access to expert support. Steps 1 Find specialists who will treat your patients and support your improvement efforts. 2 Review guidelines with specialists to get their input and buy-in. Tools and Resources Tips Seek out institutions with a similar public health mission or teaching institutions to identify specialists to work with. Teaching hospitals may agree to have residents or fellows (cardiology, optometry, podiatry, dental, etc.) rotate through your clinic, who then can help link to hospital for needed procedures. Ask specialists to be part of the team. Include specialists in the guideline development process. 3 Work with specialists to define appropriate patients for referral, based on the guidelines. 4 Work with specialists to clarify the approach to follow-up (i.e., the process for getting information to the primary care provider after the specialist sees the patient). 5 6 Develop a mechanism to track the following: • Referral made • Specialist saw patient • Specialist’s letter received by primary care provider • Patient returned to primary care provider Streamline the process for communication back and forth (e.g., fax-back forms, email, telephone conferences, telemedicine sites). The easier it is, the more likely it will happen. Use the same specialists whenever possible. Have senior leadership make follow-up between specialty and primary care provider a clear expectation at both locations. Fax-back Form Patient Encounter Form Designate a specific person to do the tracking and develop a standardized process to track referrals and information from the specialist. If possible, use the registry to track this information. Audit 5 to 6 patients periodically to see if the process is working. Use joint visits with specialists or direct phone consultation and other innovative primary care/specialist relationships. DIABETES TRAINING MANUAL 19 Decision Support ➤Provide skill-oriented interactive training programs for all staff in support of chronic illness improvement. Steps Tools and Resources Tips 1 Evaluate educational needs of staff. Keep surveys simple and easy to complete. 2 Schedule in-services routinely and opportunistically. Use multiple media for training (e.g., memos, “commercials” during in-services, sit-down in-services). Make use of existing means of reaching staff. Consider pop quizzes. Make sure CMEs are consistent with your care guidelines. 3 Use an expert, mentor, or specialist for education. Choose a person who believes in primary care as the basis for delivery of good chronic care. Rotate experts: use different disciplines (pharmacy, nursing, physical therapy, patient education, etc.). 4 Use care management conferences to encourage guideline-based practice: • Develop a multidisciplinary case review/care management team. • Determine the frequency of case reviews. • Decide how case review information will be used: - To make changes in care delivery - To educate providers - To educate patients Keep meetings brief and purposeful. Use lessons from individual patients for teaching. Make sure that “Next Steps” are part of the agenda. Review the care management conference process periodically to make sure it is still meeting a need. Make sure it doesn’t become time consuming. DIABETES TRAINING MANUAL 20 Decision Support ➤Educate patients about guidelines. (See Self-Management.) Steps 1 Develop “patient-friendly” guideline handouts or wallet cards and distribute them to patients. Tools and Resources Wallet Card www.doh.wa.gov/ndep/wallet.htm Tips Survey patients about their knowledge of disease processes. Patient Guide for Diabetes Management Be sensitive to the cultural environment of the patient and family. National Institute for Diabetes & Digestive & Kidney Disease Post information about guidelines in the clinic lobby and other public places. www.niddk.nih.gov/health/diabetes/pubs/ complications/teeth/teeth.com Indian Health Service, Patient Education Materials www.ihs.gov/medicalprograms/diabetes 2 3 Have providers reinforce patient expectations: clarify the patient’s role in making sure recommended tests and exams are completed according to the guideline. Hemoglobin A1c and Blood Sugar Targets Give patients charts of their HbA1c values, LDL, etc. Patient Tips for Good Control (English and Spanish) Mail the patients information about good control to bring with them to their visits. Include “patient expectations” as part of all support groups, health fairs, and public presentations. Evidence-Based Health Care Guideline Implementation Study Provide a script for the providers to explain patient expectations. www.qmnetwork.org Make follow-up calls (using the registry) to see if the patient followed through. DIABETES TRAINING MANUAL 21 Decision Support Materials for People with Diabetes The following resources are available at ndep.nih.gov/materials/puborder/resource.htm#people Take Care of Your Feet for a Lifetime (English and Spanish) If You Have Diabetes, Know Your Blood Sugar Numbers (English and Spanish) 7 Principles for Controlling Your Diabetes for Life (English and Spanish) This illustrated patient booklet provides step-by-step instructions for proper foot care. Includes a tear-off reminder card and a patient “To Do” list. This reproducible, black-and-white patient education brochure provides information on measuring blood sugar levels using the hemoglobin A1c test and the finger-stick test (with a blood glucose monitor) (published 8/98, updated 3/00). This easy-to-read brochure for people with diabetes describes the essential components of quality diabetes care in a checklist form. Control Your Diabetes. For Life. Tips for Feeling Better and Staying Healthy (English and Spanish) Patient education materials designed for the Native American audience, which may be useful for other populations This two-color patient education booklet provides an action plan for diabetes control that includes tips on knowing blood sugar levels, reaching blood sugar goals, and maintaining blood sugar control (published 8/98). DIABETES TRAINING MANUAL 22 Clinical Information System To provide good care for people with chronic illness, clinicians need access to timely, clinically relevant information about each patient in the practice, as well as the population of patients as a whole. Useful information includes recommended services (e.g., foot exams), key outcome measures (e.g., HbA1c, LDL), medications, and patient contact information. A system that records all relevant patient care information is often referred to as a “registry.” Providers can use the registry to record critical elements of the care plan, produce quick care summaries at the time of a visit, and enter data to alter the care plan as needed. A patient registry is most useful when patient data is available to the provider at the point of the patient visit when decision support is most needed. The registry can remind providers of needed services, represent feedback on performance of both the clinic and the provider, and serve as a source of up-to-date information for encounters. Health care teams can also use the registry to contact groups of patients with similar care needs and deliver planned care and educational sessions. Changes for Improving Clinical Information System ➤ Establish a registry. ➤ Develop processes for use of the registry, including designating personnel to enter data, assure data integrity, and maintain the registry. ➤ Use the registry to generate reminders and care-planning tools for individual patients. ➤ Use the registry to provide feedback to care team and leaders. CASE STUDY Lawndale Christian Health Center Chicago, Illinois Lawndale Christian Health Center made a commitment to enter data on all of their diabetic patients (approximately 1,000) into an electronic registry. The intention was to use the registry to present graphs to patients, demonstrating their progress with average HbA1c at each visit; generate monthly reports for individual providers, senior leadership, and the Board of Directors; create an effective mechanism to communicate with outside funders and agencies about the center’s diabetes population; and respond to queries regarding patients at risk or in need of specific tests and follow-up. Initially, the physician champion entered all data herself, but as the process spread to more patients and providers, the team realized that they needed more help—both for data entry and training additional staff. They approached the receptionist to ask if she could assist with lab data entry. Not only was she glad to help, but also she took pride in the fact that she was involved in this important collaboration to improve the health of the health center’s diabetic patients! This fervor has now spread to all of the nursing assistants, who are trained in data entry for new diabetic patients and printing off the registry form for patient visits. The registry is now available on all computers at Lawndale via a network, and it has been promoted as a means to improve adherence to standards. DIABETES TRAINING MANUAL 23 Clinical Information System Creating an Electronic Registry of Your Patients Identifying and keeping track of the patient population is the backbone to delivering population-based care. A registry is a mechanism for keeping all pertinent information about a specific group of patients at your fingertips. The Bureau of Primary Health Care, along with the Centers for Disease Control, has supported the development of several diseasespecific electronic registries (Microsoft Access-based), which are available to all health centers free of charge: DEMS (Diabetes Electronic Management System) for diabetes and CVDEMS for cardiovascular and diabetes combined. Work is also progressing on a more generalized registry; check www.healthdisparities.net for updates. There are hardware and software considerations for using the electronic registry. For instance, CVDEMS requires that a clinic have one working copy of the Microsoft Access program (Access 97 or Access 2000), a printer (preferably color), and at least 32 MB RAM and about 20 MB of free space on the hard drive. See the Computer Assessment Tool at www.healthdisparities.net for a full list of hardware and software requirements for the use of CVDEMS. Integration of an electronic registry into your center’s operations will require a team approach represented by key personnel: physicians, nurses, medical records, front-line support staff (clerical, medical assistants), information systems (if available), and administration. Please refer to the list of questions in the Registry Assessment Tool at www.healthdisparities.net for the types of resource and redesign issues you will face. DIABETES TRAINING MANUAL 24 Clinical Information System ➤Establish a registry. Steps 1 Tools and Resources Choose or develop an electronic or manual registry. Electronic Method: Choose a computer application that allows for flexible data handling and reporting. Make sure the application makes it easy to get patient information into and out of the system. It should also be easy to transfer information to and from other systems (e.g., billing, lab, appointments), or even have a direct interface with these systems. Electronic Registry Constructing a Registry Registry Assessment Tool Computer Assessment Tool Tips Choose software that can capture needed data from existing computer systems and is within budget. Visit a center with a well-implemented patient registry. Keep manual data entry to a minimum. Whenever possible, transfer information electronically from systems like appointments and billing. Remember that a registry is NOT an automated medical record. A registry is a repository of essential care elements based on a care guideline. Manual Method: Develop a card file or notebook that can be used to track patient information. Identify team members with good computer skills to manage the registry and train others how to use it. Tools and Resources Icons Web link Form/Tool that may be accessed on www.healthdisparities.net Book or periodical reference Form/Tool that may be accessed via a web link to another site Phone reference DIABETES TRAINING MANUAL 25 Clinical Information System ➤Establish a registry. (continued) Steps 2 Decide on what data to include in the registry, based on the essential elements of good diabetes care. (See Decision Support.) Tools and Resources Chart Abstraction Form Diabetes Care Chart Audit Definition of Homelessness Track II: National Tracking and Referral Project for Migrating Patients with Diabetes Migrant Clinicians Network www.migrantclinician.org Health Care for the Homeless Clinicians’ Network 615-226-2292 [email protected] www.nhchc.org Tips Use precise and consistent definitions for each key measure. Make sure you capture information required by accrediting bodies or managed care organizations. For example, define a retinal eye exam the same way for the provider as you would for HEDIS. Start small, but make sure the system lets you add new data elements as guidelines change and providers become more sophisticated. Don’t overwhelm people with too much information at first. Don’t forget to include the following, which are cultural indicators that can help you reach migrant and homeless patients and other underserved populations: • Ethnicity • Language • Insurance coverage • Patient mobility Contact the Bureau of Primary Health Care’s Health Care for the Homeless program and the Migrant Clinicians Network to obtain information on items to include for mobile populations. Make sure that your registry will also be useful for reports: • Quality Improvement projects • Provider feedback • Grant applications • Financial management • HEDIS • Special populations DIABETES TRAINING MANUAL 26 Clinical Information System ➤Establish a registry. (continued) Steps 3 4 Document how you established the data elements on a template, so that new staff can replicate the process. Build the registry by using an existing information system to identify the majority of patients with diabetes. For example, add names from billing data or the ICD9 250.xx list for the last calendar year. Add names as new patients join the clinic. Tools and Resources Sample Registry Report Tips Keep the template simple and easy to use. Use the tool in the CVDEMS registry to import DEMS data. Many of the existing systems (especially Excel- and Access-based) also have easy-to-use data import features. Try to include all diabetic patients, even if the practice doesn’t recognize or claim them. Most providers dramatically underestimate the number of patients with diabetes in their patient population. Work with information systems experts to develop ways to update the registry monthly, based on billing, pharmacy, and lab data. 5 Share the list of diabetes patients with the practice team to eliminate miscodes. Have team “clean” the list by noting patients who are not diabetic, who have long since moved out of the area, or who have died. Some groups perform a chart audit to clean the registry. Review the registry for accuracy. If too many people with diabetes are missed, providers won’t trust the registry. In many cases, it takes an actual patient visit to determine if someone should not be in the registry. However, most health centers have found most inaccuracies through a chart audit. Flag gestational diabetes as appropriate. DIABETES TRAINING MANUAL 27 Clinical Information System ➤Establish a registry. (continued) Steps 6 Document the process of identifying patients as “inactive.” Tools and Resources Tips Use the following definition: patients with diabetes (Type 1 and Type 2) who were continuously enrolled during the year and who have at least one visit to the clinic within the past calendar year are considered clinic patients unless there is documentation that the patient has transferred to another practice or has moved from the area. In addition, clinics with managed care plans should try to include patients with diabetes who have no documented medical visit to the clinic, and who have been assigned to the clinic for 12 months, with no more than a 45-day drop in coverage. ICD-9 code of 250.00 –250.99. Tie the registry update process to standard forms to be completed when a patient dies or is removed from the clinic roster. 7 Use color dots to identify the medical records of persons with diabetes. Place a tab in chart, color-coded stickers, and/or “Foot Exam” sticker to identify records of persons with diabetes. Ensure patient confidentiality. (Don’t write or type “Diabetic” on the outside of the chart.) DIABETES TRAINING MANUAL 28 Clinical Information System ➤Develop processes for use of the registry, including designating personnel to enter data, assure data integrity, and maintain the registry. Steps 1 Develop tools for collecting data. (Use computer programming to capture electronic data when available.) Tools and Resources Tips Use DEMS or CVDEMS Visit Note. Many of the existing registries have Visit or Encounter Notes that provide the focal point for data collection. If you’re not using DEMS or CVDEMS, use a data collection sheet. Include homeless/migrant status on the data collection tool to identify an important subpopulation. 2 3 Train people who will be collecting and entering data into the registry. Include test cases for entering data. Periodically have two team members enter the same data and check on reliability. Create a process for data entry. It is best to enter data directly into the registry during the visit. Even if this is not currently possible, make sure the process is well described so that it can eventually become part of people’s daily work. Data entry and maintenance are part of the center’s daily operations, not an “add-on” task at the end of the day. Ensure that the data entry person is given time to enter data in “real time.” Enlist senior leader’s support. Periodically check registry data against your data entry sheet. Perform data entry on the day the data becomes available. Include clinic visits, lab work, outside visits, tests, and education. Look at your current data flow and minimize handoffs. Consider using trained volunteers to enter data. Enter data at point of service if computers are available in examining rooms. DIABETES TRAINING MANUAL 29 Clinical Information System ➤ Develop processes for use of the registry, including designating personnel to enter data, assure data integrity, and maintain the registry. (continued) Steps 4 Schedule and produce reports. Tools and Resources Tips Include reports for: • Providers • Managers • Board of Directors • Referral clerks Enlist Risk Management support: The identification of high-risk patients and timely attention to standards of care can be an important defense against lawsuits. 5 Ensure system security. Use password protection. Determine who has read/write access and who decides about access. Make sure computer terminals in public places don’t violate confidentiality. 6 Make sure that people who need information from the system can get it in a timely manner. Design front-end “buttons” for one-touch printing of reports and forms. Use fast printers if possible. 7 Make sure staff are trained on data entry, backup, and security procedures. Make training on the system part of orientation for all staff. Use an orientation checklist for consistency. DIABETES TRAINING MANUAL 30 Clinical Information System ➤ Develop processes for use of the registry, including designating personnel to enter data, assure data integrity, and maintain the registry. (continued) Steps 8 Tools and Resources Establish system backup. Tips Schedule and test backups. Determine who is responsible for backup and when/how frequently backups are done. An example of an effective system backup plan… Who will back up your data? Jim will be in charge of backing up the data. When will you back up your data? Jim will back up the data file every Thursday afternoon at 2:30 p.m. during his admin break. Which method will you use to back up your data? Jim will add the data file to a zip file and copy that zip file onto a floppy disk. Where will you keep your backups? Jim will put the disks in the disk holder labeled “CVDEMS Backups,” which will be kept in the medical records office. We will keep 4 weeks of backups at any time in this disk holder: the most recent backup (week 4), the least recent backup (week 1) and the second-to-the-least-recent backup (week 2). Jim will put the second-to-the-most-recent backup (week 3) in the secure filing cabinet in the administration building. DIABETES TRAINING MANUAL 31 Clinical Information System ➤Use the registry to generate reminders and care-planning tools for individual patients. Steps 1 Use patient treatment record forms that include services needed at time of visit. Before a visit, print out current information from the registry. Tools and Resources Tips Determine how to identify patients with diabetes prior to a visit, and create a process to ensure that the treatment record form is on the chart in the examining room. Determine if your appointment system has the capability to flag patients with diabetes. Flag charts to help identify patients with diabetes. 2 Use the registry periodically to generate lists of patients who are missing a service or have a service that is overdue. Database queries might include the percentage of patients with each of the following criteria: • 2 HbA1c measurements in 1 year, at least 3 months apart • Foot exams • Retinal exams • Renal screen and appropriate treatment • HbA1c > 8 3 Use the registry to generate lists of high-risk patients for specialized care and follow-up. Create a protocol for which you are going to follow up and how. Use lists to send reminders by mail or make follow-up phone calls. To protect patient confidentiality, do NOT use postcards. Use patient wallet cards to remind patients what needs to be done, when. Create a take-home patient summary sheet. Create a protocol for which patients you are going to follow up and how. Database queries might include: • Patients with BMI > 25 • Smokers • Patients not seen in last year • Patients with high-risk feet • Patients with multiple co-morbidities • Patients with HbA1c > 9 DIABETES TRAINING MANUAL 32 Clinical Information System ➤Use the registry to generate reminders and care-planning tools for individual patients. (continued) Steps 4 Divide the population of diabetes patients into categories (e.g., ethnicity, language, insurance, needs/limits, homelessness) to identify special needs. Tools and Resources Health Care for the Homeless Clinicians’ Network 615-226-2292 [email protected] www.nhchc.org Tips Alert community partners to keep you updated on new ways to meet the needs of these populations. See ideas in “Care Model: Changes for Specific Populations” section of this manual. 5 Decide how to handle patients with missing services. Consider using planned visits, fitting diabetes care into acute care visits, and group visits. (See Delivery System Design.) Have a team huddle at start of day to review that day’s patients for missing services. 6 Use the registry to invite patients to health fairs, informational meetings, etc. Assign the role of keeping updated on community activities to a team member. Create electronic links between registry and mailing programs. 7 Use the registry to identify the under-insured population to solicit for special services and medical assistance programs. Establish linkages to community wellness programs for the poor. Partner with existing community coalitions to build linkages to other community-based organizations. DIABETES TRAINING MANUAL 33 Clinical Information System ➤Use the registry to provide feedback to care team and leaders. Steps Tools and Resources Tips 1 Decide which elements or fields in the registry, and which subgroups of patients, to report on. Keep it simple. 2 Develop a format for feedback. Allow for formatting suggestions after first draft, but don’t try to reach consensus across all end-users. Use feedback reports that are automated and easy to produce. Standardize reports across teams for easy interpretation and comparison. 3 Decide who receives feedback and how often. Send monthly reports to Board, senior leaders, and team. Show blind comparison data of other providers to motivate providers. Have managers evaluate and support outliers. Incorporate CME with data feedback as a decision support service to providers. DIABETES TRAINING MANUAL 34 Delivery System Design Effective management of chronic illness requires more than simply adding interventions to an existing system focused on acute care. Rather, it necessitates basic changes in delivery system design. These changes require a shift of emphasis to “planned” visits instead of acute visits. Effective management often requires expansion of staff member roles and responsibilities. These changes include all professionals (e.g., nurses, health educators) who have the knowledge and time to carry out the range of tasks required to manage complex chronic conditions. Staff members also need timely access to key clinical data, enough time to interact with patients, and regular, planned follow-up with patients. Meeting these needs often requires innovation in the scheduling and organization of care, such as group or individual planned visits. Changes for Improving Delivery System Design ➤ Use the registry to proactively review care and plan visits. (See Clinical Information System.) ➤ Assign roles, duties, and tasks for planned visits to a multidisciplinary care team. Use cross-training to expand staff capability. ➤ Use planned visits in individual and group settings. CASE STUDY High Plains Community Health Center Lamar, Colorado There are some very satisfied patients and staff at High Plains Community Health Center these days. The center initiated a Diabetes Clinic in which the patient has a planned encounter with the provider and a number of other staff. Some changes revealed the need to cross-train the staff to perform multiple functions so that the patient is not short-changed if there is illness or an emergency on the part of one of the four staff who provide assessment and care at the Diabetes Clinic. The patient is prepared in advance with pre-ordered labs and what to expect during the visit. The nursing staff orders labs according to protocols, as well as performs foot assessments and education, thereby freeing the provider to spend more time with the patient on setting goals and discussing problematic areas. The Diabetes Clinic is a “4-in-1” visit, with the patient having a foot, dental, dietary, and medical provider assessment. ➤ Make designated staff responsible for follow-up by various methods, including outreach workers, telephone calls, and home visits. ➤ Use promotoras and community health worker programs for outreach. DIABETES TRAINING MANUAL 35 Delivery System Design ➤Use the registry to proactively review care and plan visits. (See Clinical Information System.) Steps 1 2 Tools and Resources To institute proactive care, review the registry to identify population-based needs (e.g., eye and dental exams) and plan group visits/mailings/fairs/reminders to patients to meet those needs. Use planned visits. The provider care team: • Identifies diabetic patients coming in for an appointment the next day. • Looks at registry data and identifies needs on flow sheet/visit note/encounter note. • Plans visit, including who will draw labs, make referrals, and do self-management goals. Tips Use the reports from the registry that can answer the many patient care-related questions (e.g., “List all patients who have not had an HbA1c in 6 months”). Sample Registry Report Conducting a Continuing Care Clinic: Handbook for the Practice Team Schedule regular staff time for population review. Look for areas for improvement, e.g., smoking cessation, blood pressure control, and foot exams. Use daily huddles for staff to communicate patient needs. Use daily care team meetings to prepare for the day’s planned visits. Consider having patients come in a few days before an appointment for blood draw so that lab results are available at the time of the appointment. Consider “one-stop shopping” appointments with multiple providers for patients with many overdue needs. 3 Use care flow sheets, charting templates or similar tools to guide care and follow-up. (See Clinical Information System.) Diabetes Flow Sheet Use mail merge software for mailings/reminders. Tools and Resources Icons Web link Form/Tool that may be accessed on www.healthdisparities.net Book or periodical reference Form/Tool that may be accessed via a web link to another site Phone reference DIABETES TRAINING MANUAL 36 Delivery System Design ➤Assign roles, duties, and tasks for planned visits to a multidisciplinary care team. Use cross-training to expand staff capability. Steps Tools and Resources 1 Determine who has responsibility for each step of the planned visit. 2 Obtain senior leader support for training staff in new roles and tasks. 3 Identify who will do the training. 4 Identify resources, training material, and tools. Training materials, e.g., Lower Extremity Amputation Prevention (LEAP) Program 5 Offer opportunities for the staff member being cross-trained to shadow or observe the staff member doing the procedure (e.g., foot exam). bphc.hrsa.gov/leap/ 6 Train providers, medical assistants, nurses (e.g., in LEAP exam, self-management goal-setting and follow-up, phlebotomy), and periodically check staff competency with tasks. 7 Use standing orders for referrals. • Query registry monthly for all diabetes patients due or overdue for eye or dental exam. • Give list of due or overdue eye or dental exams to designated referral person, who then makes referral automatically from monthly list of overdue exams, etc. 8 Use standing orders for labs. • Develop standing orders for RN or dietician. • Educate RN and dietician on use of standing orders. • Use registry to identify patients who need labs and send letters to patients requesting they get them. Tips Beware of relying on volunteers: they should be under the supervision of a paid employee so that if the volunteer is unable to do the task (e.g., follow-up phone calls), the supervisor is aware and can make other plans. “Feet Can Last a Lifetime” Kit (2000), National Diabetes Education Program (includes ready-to-use exam forms, patient education handouts, etc.) ndep.nih.gov/materials/pubs/feet/feet.htm Standing Orders DIABETES TRAINING MANUAL 37 Delivery System Design ➤ Use planned visits in individual and group settings. Steps 1 Obtain senior leadership support for planned visits, especially to resolve potential reimbursement issues relating to group settings. 2 Block time for providers in advance. 3 Use registry to identify patients in need of visits. 4 Have promotoras, community health workers, volunteers, or appointing staff call and schedule patients for visits. 5 Train staff in planned visit approach. A planned visit should contain an assessment, review of therapy, review of medical care, self-management goals, problem solving, and follow-up plan. Tools and Resources Have planned visits be part of the health center’s stated philosophy of care. ETHNIC: A Framework for Culturally Competent Clinical Practice, Organization Assessment Form www.state.nj.us/health/bibs/education/ethnic.html 6 Assemble a patient visit team (provider, certified diabetic nursing assistant, promotoras, intake worker, lab, immunization, and referrals). 7 Use group visits to deliver care. A group visit brings together 8 to 20 patients to deliver medical care in a group setting; all patients are in the same room, and providers come to the group to take vital signs, discuss issues, and answer questions. Tips Be cognizant of cultural diversity in your patients and use ETHNIC as a framework for culturally competent clinical practice. Make group visits multidisciplinary, including dental, podiatry, and ophthalmology. Try holding group visits at homeless shelters, housing or faith-based organizations. Group Visit Starter Kit Planning Group Visits for High-Risk Patients, American Academy of Family Physicians www.aafp.org/fpm/20000600/33plan.html DIABETES TRAINING MANUAL 38 Delivery System Design ➤Make designated staff responsible for follow-up by various methods, including outreach workers, telephone calls, and home visits. Steps 1 Identify follow-up needs, such as eye exam, dental care, HbA1c, labs, and visits. 2 Plan the follow-up approach, including who will contact patients, how, and when. 3 Use phone, outreach workers, and mailings for follow-up. Tools and Resources Tips Generate reports from the registry to discover those patients in need of follow-up and generate contact lists. Ask patients for best methods and times to follow up for check-back visit, pharmacy refills, etc. DIABETES TRAINING MANUAL 39 Delivery System Design ➤ Use promotoras and community health worker programs for outreach. Steps 1 Get senior leadership support and solicit help in hiring and/or recruitment. 2 Identify responsibilities of promotoras and community health workers (see tips column), and plan how they will be documented. 3 Train promotoras and community health workers. 4 Provide job shadowing for LEAP (Lower Extremity Amputation Prevention) exam and counseling. 5 Evaluate skill level of health workers periodically. Tools and Resources Credentialing of Promotoras fax: 956-447-0553 Words to the Wise, Bilingual Course for Diabetes Promotoras, New Mexico Department of Health Diabetes Control Programs 505-827-2953 Tips Try using the promotoras and community health workers for: • Clinical follow-up • Community screening • Home visit for follow-up care • Participation in group visit If promotoras are unpaid volunteers, provide periodic incentives such as paper certificates of appreciation, a local newspaper story, awards recognition lunch, personalized tools such as name tags or a blood pressure cuff (often pharmaceutical companies will pay for such items). DIABETES TRAINING MANUAL 40 Organization of Health Care Health care systems can create an environment in which organized efforts to improve the care of people with chronic illness take hold and flourish. Critical elements include a coherent approach to system improvement, leadership committed to and responsible for improving clinical outcomes, and incentives to providers and patients (including nonfinancial incentives such as recognition and status) to improve care and adhere to guidelines. Changes for Improving Organization of Health Care ➤ Make improving chronic care a part of the organization’s vision, mission, goals, performance improvement, and business plans. ➤ Make sure the senior leaders and staff visibly support and promote the effort to improve chronic care. ➤ Assign day-to-day leadership for continued clinical improvement. ➤ Integrate Collaborative models into the Quality Improvement program. CASE STUDY Salud Para La Gente, Inc. Watsonville, California The population served at Salud Para La Gente is primarily migrant farm workers and their families. Fifty-seven percent of the patients are uninsured. One significant barrier identified by the diabetes team was that the patients were unable to afford the medications they needed to manage their condition. Senior leadership supported the efforts and provided the resources to develop and maintain a tracking system to enroll eligible patients in an Indigent Pharmacy Program. The team developed a tickler system that prompts the reapplication process and helps assure that diabetic patients are receiving the medications they need to control their condition—while saving the health center more than $30,000 a month. In addition to the senior leader’s support, the executive director plays an active role on the diabetes team, attending Learning Sessions and team meetings regularly and helping to eliminate multiple barriers along the way. DIABETES TRAINING MANUAL 41 Organization of Health Care ➤ Make improving chronic care a part of the organization’s vision, mission, goals, performance improvement, and business plans. Steps 1 2 Tools and Resources Link diabetes measures and outcomes to the strategic business plan: • Identify expense revenue from the organization’s Chief Financial Officer. • Conduct a unit cost analysis by activity center. For diabetes patients, model the unit cost. • Document change/time in outcome and document treatment time of patients. • Document revenue from ancillaries. Tips Business Case for Disease Management www.improvingchroniccare.org Discuss with senior leader the direct impact that improved outcomes have on the organization. Provide references of other senior leaders who have undertaken the same effort. Assist senior leader in determining the “value” of improving chronic illness care (e.g., quality, accreditation, increased productivity/efficiency, business case, and more patients). Test different ways to get senior leader’s support. For example, present to the senior leader in the language or areas of “worry” that the senior leader thinks in. Ask the Collaborative Directors for support and advice. Involve the senior leader early on. Involve the senior leader in developing an aim, and ask the senior leader for feedback on the draft aim statement. Discuss the team’s choice of measures and how they impact the organization and the patients. Tools and Resources Icons Web link Form/Tool that may be accessed on www.healthdisparities.net Book or periodical reference Form/Tool that may be accessed via a web link to another site Phone reference DIABETES TRAINING MANUAL 42 Organization of Health Care ➤Make improving chronic care a part of the organization’s vision, mission, goals, performance improvement, and business plans. (continued) Steps 3 Gain the senior leader’s interest with reports and feedback. Tools and Resources Tips Use the Senior Leader Report, graphs, and registry report, eliminating the need for a special report to be created for the senior leader. Make a standing monthly appointment with the senior leader/team leader and team to discuss Senior Leader Report. Provide Senior Leader Report 2 or 3 days prior to meeting for review time and as a reminder of the appointment. Understand the data! Know what the issues/barriers are, and present them in an objective manner that invites the senior leader to contribute. 4 Involve senior leadership with the team’s work. Invite the senior leader to team meetings. Assign the senior leader work in removing barriers. Involving the senior leader in work and decision making helps build trust that the team will do the right thing. Involve the senior leader in marketing the outcomes in the community for partnership development. DIABETES TRAINING MANUAL 43 Organization of Health Care ➤Make improving chronic care a part of the organization’s vision, mission, goals, performance improvement, and business plans. (continued) Steps 5 Tools and Resources Have the team leader or physician champion regularly report Collaborative work to Board of Directors. Tips Keep it simple! Provide a straightforward report that everyone can understand; avoid being too technical or too clinical. Provide patients’ own words or reactions whenever possible, or discuss provider satisfaction. Provide printed reports and, if possible, do overheads of graphs. Present barriers to progress (e.g., transportation, eye care, resource development) to Board of Directors and seek their help in overcoming the barriers. 6 7 Show Health Disparities Collaboratives training and promotional videos to introduce senior leaders, Board of Directors, and staff to Collaborative work. Place storyboards in places visible to staff and patients. Changing Practice, Changing Lives: The Health Disparities Collaboratives, Training and Promotional Videos Use this excellent tool to get others involved. www.healthdisparities.net Post a sign reading, “For further information, contact xxxxx.” Create an “HbA1c Club” bulletin board where patients who drop their HbA1c by 1% get their picture taken (with their consent, of course) and put up on the board — a real reward for them and a motivator for other patients and staff. 8 Post Senior Leader Report/graphs so staff can review. Assign team member to change posting monthly. Post a sign reading, “For further information, contact xxxxx.” DIABETES TRAINING MANUAL 44 Organization of Health Care ➤Make sure the senior leaders and staff visibly support and promote the effort to improve chronic care. Steps Tools and Resources Tips 1 Encourage the senior leader to: • Visit the clinical team. • Speak about the improvement effort in all-staff meetings. • Participate in writing the aims and goals of the diabetes initiative and provide guidance for the clinical team. • Make monthly updates to the community. Invite the senior leader to make a 10-minute presentation to the “community” at a group diabetes class (make sure it is after the class has been well-established so that there will be enough people there to make it worthwhile). Ask the patients at the class to give the senior leader feedback. 2 Present local morbidity/mortality diabetes data to the Board of Directors to make a compelling case for the need to change current practice. Ask for Board of Directors’ support early and often. Have the physician champion share tested tools and interventions at provider meetings to engage interest and involvement. As tools are tested and proven, ask interested providers to try them. 3 Give feedback to Board regarding how support has made a difference. Discuss data that is available from registry and uses for data. Provide copy of DEMS flowsheet for review. At every provider meeting, share something positive: a patient case study or a tool. Involve providers by asking for their input and ideas. Don’t be afraid to share “learning opportunities” — the ideas that did NOT work. Present patient cases from which providers can learn about pitfalls, and reduce the fear of presenting mistakes, dead ends, trials that show us what doesn’t work and why. “Get messy! Make mistakes!” DIABETES TRAINING MANUAL 45 Organization of Health Care ➤Make sure the senior leaders and staff visibly support and promote the effort to improve chronic care. (continued) Steps 4 Have team members present Collaborative activities at staff meetings. Tools and Resources Tips Ask the senior leader or Medical Director to formally introduce the Collaborative and team to promote the effort and ask other staff to help when needed. Provide patient comments as appropriate. Be enthusiastic, so that others will want to participate. 5 Have the senior leader help identify the most enthusiastic and respected clinician to be on the improvement team and test changes in his/her practice. DIABETES TRAINING MANUAL 46 Organization of Health Care ➤Assign day-to-day leadership for continued clinical improvement. Steps 1 Have the senior leader provide time for a dayto-day team leader to manage the initiative. 2 Have the senior leader identify an enthusiastic and respected clinician to champion the work and the team. Tools and Resources Tips Ask the Medical Director to advocate for providing sufficient time for the day-to-day leader’s work. Choose a physician champion with the following characteristics: • Commitment to improve/change the system • Ability to articulate needs of team without alienating others • Willingness to be a team member, not the team Have the team leader deal with day-to-day activity, so that the physician champion will not be overloaded. 3 Gain the partnership and trust of the CEO and the Medical Director so that they will formally delegate authority to the team to make change. 4 Select the improvement team and establish a regular meeting time. 5 Engage administrative and clinical staff in the diabetes project, so that people at all levels are aware of the improvements. 6 Regularly evaluate the team process. 7 Make maintaining the progress part of ongoing work. 8 Consider making the team a “pilot” with plans to train other teams. Make support of and participation in the diabetes effort part of the annual evaluation for all staff. Health Disparities Collaboratives Train-theTrainer Manual for Health Centers Senior leader should set this expectation early; staff will be more willing to help because they will want help when their turn comes. DIABETES TRAINING MANUAL 47 Organization of Health Care ➤Integrate Collaborative models into the Quality Improvement program. Steps 1 Tools and Resources Enlist the person responsible for quality in the organization as a team member. Tips Provide Prework Manual for review and reference. Involve quality person in aim and measure development. 2 3 4 5 Get the team leader or physician champion on the Quality Improvement Committee (QIC) agenda each meeting to present some aspect of the improvement work. Provide a copy of this manual for all members. Engage the Quality Improvement Committee in discussion of barriers or ideas to test. Present barriers and ask for ideas. Integrate the models (Care Model and Improvement Model) into the quality improvement plan and use them for all improvements. If possible, use overheads for graphs. Report back on successes! Care Model www.improvingchroniccare.org Improvement Model Work with quality improvement person to integrate models into written plan. Plan training of all staff on the Improvement Model. Send all tested and implemented change ideas to all sites early for implementation. DIABETES TRAINING MANUAL 48 Community Linkages between health clinics and community resources such as health departments, churches, senior centers, and YMCA/YWCAs are crucial to the success of comprehensive chronic illness care programs. Clinics form partnerships with community organizations to develop evidence-based programs, resources, and health policies that support patients in their efforts to manage chronic disease. Clinics with strong linkages to the community make special efforts to coordinate chronic illness guidelines, measures, and resources throughout the community. Clinics that make these important links to community resources improve patient care and outcomes and enable communities and patients to take an active role in managing chronic illness. Changes for Improving Community ➤ Establish linkages with organizations to develop support programs and policies. ➤ Link to community resources for defrayed medication costs, education, and materials. ➤ Encourage participation in community education classes and support groups. ➤ Raise community awareness through networking, outreach, and education. ➤ Provide a list of community resources to patients, families, and staff. CASE STUDY Dimock Community Health Center Roxbury, Massachusetts Dimock CHC conducted a community-based needs assessment, surveying residents on prevalence of diabetes and related symptoms, access to care, cultural and linguistic needs and barriers, and reviewed a regional analysis conducted on bilingual diabetes initiatives funded by the Commonwealth Fund and others to assess the needs of the community. Based upon a data summary that presented the results of the assessment and identified barriers to care and access, the CHC approached local leaders in diabetes care, Beth Israel-Deaconess Medical Center (BIDMC) and the Joslin Diabetes center, about partnership to develop a communitycentered response to the needs assessment. Dimock CHC subsequently received initial seed funding from BIDMC for outreach workers (for one year) and in-kind and financial support for clinical staff and technical assistance from the Joslin (for four years). In addition, Dimock applied for a grant with technical assistance from the local DPH (funded for 15 months), developed community service rotations with Northeastern University, Harvard Medical School, and Emmanuel College nursing and medical programs, and joined Latino Diabetes and REACH 2010 community coalitions, among others. DIABETES TRAINING MANUAL 49 Community ➤Establish linkages with organizations to develop support programs and policies. Steps 1 Tools and Resources Identify key community organizations (churches civic groups, clubs, schools, hospitals, banks, etc.) and let them know ideas for what they can do to improve care of people with diabetes. The community is a trusted access point for reaching people with diabetes, their families, and their friends to support them in learning more about diabetes and gaining control over it. Tips National Diabetes Education Program, Diabetes Community Partnership Guide, page 51, “Organizations Making a Difference with 18 Easy Ideas.” ndep.nih.gov/materials/pubs/communityguide/community-guide.htm National Diabetes Education Program 800-438-5383 or ndep.nih.gov Center for Disease Control and Prevention 2 3 4 Identify local/state interest groups: PCA (Primary Care Association), Diabetes Control Program (DCP), etc. Before developing a relationship, review missions of different organizations to ensure compatibility. Identify team/clinic needs (technical, staff, hardware, strips, etc.) and approach other community organizations for help. www.cdc.gov/diabetes. Translation for Educational Materials: www.freetranslations.com www.systranet.com Find sources for interpreters to assist with education, training materials, etc. Get feedback from community partners to find out how they can provide support for the community learning more about diabetes, and to suggest others who might be willing and able to play a role. Review partnerships to determine which are politically or financially worth continuing. Use data from the registry to help other organizations understand the needs of your diabetic population and to show them the results of any improvements you have made. Diabetes Today National Training Center training and technical assistance on applying a community mobilization model, Diabetes Today www.diabetestodayntc.org/ Summit Health Institute for Research and Education (SHIRE), faith-based relationships 301-559-4400 Tools and Resources Icons Web link Form/Tool that may be accessed on www.healthdisparities.net Book or periodical reference Form/Tool that may be accessed via a web link to another site Phone reference DIABETES TRAINING MANUAL 50 Community ➤Establish linkages with organizations to develop support programs and policies. (continued) Steps 5 Request education and services from universities, colleges, and extension services. 6 Develop memoranda of understanding or similar documents as needed to define partnerships. 7 Prepare a brief presentation that outlines the goals of the diabetes project, the mission of your organization, and what you are striving to do for the community you serve. Offer to do the presentation to local service organizations, ADA conferences, university- or professional organization-sponsored workshops. 8 Work with Americorps or VISTA to place staff to work on the diabetes project. 9 Ask for community representatives to attend and be part of advisory groups. 10 Identify clinic leadership to serve on community boards. Tools and Resources PCA Directory Listing State Based Programs to Reduce the Burden of Diabetes Tips Use high school and college students pursuing careers in health to provide patient outreach, computer expertise, materials development assistance, etc., as part of a school project. Present your needs to schools. Periodically review partnerships and agreements to determine success. Americorps www.americorps.org/ DIABETES TRAINING MANUAL 51 Community ➤Link to community resources for defrayed medication costs, education, and materials. 1 Steps Tools and Resources Tips Request supplies (glucose meters, strips) and unrestricted grants from pharmaceutical firms and local stores/pharmacies. Usually, all that is needed is a letter (signed by an MD always helps) requesting an unrestricted educational grant or an unrestricted grant to improve diabetes patient care. Usually $500 to $1000 can be obtained from a single company without difficulty. Contact your local pharmaceutical company representatives and ask what is required to obtain such a grant from their firms. Patient Prescription Services: When approaching organizations for help, quantify requests clearly. Bayer Corporation/Bayer Indigent Patient Program 800-998-9180 Bristol-Myers Squibb Patient Assistance Program 800-437-0994 Eli Lilly & Company/Lilly Cares 800-545-6962 Hoechst Marion Roussel, Inc./Indigent Patient Program 800-2114025 NovoNordisk Pharmaceuticals Inc/ Indigent Program 800-727-6500 Pfizer Inc/Pfizer Prescription Assistance • Example: Request for free strips from Bristol Meyers for one year 500 patients x $60/mo x 12 months = $360,000 Distribution costs per patient (staff time + mailing + data entry) = _____________________ Total = _____________________ • Example: Request for support for referring 50 patients for diabetic classes at the YMCA The health center will provide the transportation. 50 x $3.00 = $150 3 hours of staff time for scheduling, etc. $10 x 50 patients = $500 (covered by the Women’s Group at the Baptist Church) Total = _____________________ Make face-to-face contact for requests. This generally works better than letters, except for formal grant requests. Patient Prescription Services is a company that helps indigent patients get meds from pharmaceutical programs with much less effort than the usual application process. It comes as a software package or a direct service. The software package has been previewed by MCN; it allows provider modification, acting as a medicine flow sheet and problem list. Ask all pharmaceutical representatives who detail the office for unrestricted grants to support the effort. Ask the senior leader to allow staff to present to potential funders as paid time. DIABETES TRAINING MANUAL 52 Community ➤Link to community resources for defrayed medication costs, education, and materials. (continued) Steps 2 Obtain free passes/memberships from local YMCA/YWCA for people with diabetes. Don’t forget about free passes to other places that encourage walking as a physical activity (the zoo or botanical gardens, etc.). 3 Request in-kind services from local specialty groups (ophthalmology, endocrinology, dental, etc.). Tools and Resources Tips National Eye Care Project Helpline, No-Cost Ophthalmology Exam 1-800-222-EYES. American Optometric Association, Optometry Referral and Follow-up 800-262-3947 4 Involve the clinic pharmacy to increase participation in drug assistance programs. 5 Develop form with pharmacist for each indigent program. Make arrangements with local pharmacy. Maintain a sample application from each patient using the indigent drug program to use for obtaining refills. Tie refills in with planned visits (see Delivery System Design). 6 Identify community provider resources (e.g., specialists, dentists) for referral. Present information about the diabetes improvement project and request funding. DIABETES TRAINING MANUAL 53 Community ➤Link to community resources for defrayed medication costs, education, and materials. (continued) Steps 7 Complete a grant request to the local Diabetes Control Program for additional staffing/equipment (e.g., computers). 8 Request funding from service organization (Lions, etc.) for specific item or equipment or services (e.g., Bayer DCA 2000). 9 Complete grant requests from national organizations (e.g., Pearle Vision). 10 Request discounts on fruits/vegetables or catered meals for special education programs or health fairs from local grocery chains. 11 Advocate for expanded Medicaid benefit packages. Tools and Resources Tips Ask senior leaders and Board of Directors to help you identify and find possible grant opportunities or funding sources. Invite Medicaid managed care leaders to be involved in the team. DIABETES TRAINING MANUAL 54 Community ➤Encourage participation in community education classes and support groups. Steps 1 Review class curricula for compatibility with the clinic’s self-management approach and cultural differences. 2 Review the system for referring patients to the community agency offering the class or group. 3 Use the registry to mail out fliers to patients. Include an endorsement from providers or respected community figures. 4 Use volunteers to remind patients. 5 Maintain close communication with the community sponsor. 6 Evaluate class/group with patients. Tools and Resources Culturally Appropriate Patient Education Materials, Office of Minority Health www.omhrc.gov/ Tips Make sure the agency offering the class/group has a similar mission to yours and that both will benefit from the referrals. Be willing to work with the agency to help make their curriculum compatible. Constantly keep cultural sensitivity in mind. Assign a staff member to be a key contact and identify a key contact at the partner agency. “Prescribe” the class/group using a prescription pad. Anticipate that transportation to classes/groups may be a barrier for some patients, and find solutions. Keep in touch with patient participants if it is an ongoing class/group to determine problems, barriers, and provide feedback and support. If the cost of patient education classes is a problem for some uninsured patients, offer to trade: A staff physician will talk at a class about diabetes meds or complications in return for a “scholarship” for an indigent patient to take the classes. DIABETES TRAINING MANUAL 55 Community ➤Raise community awareness through networking, outreach, and education. Steps Tools and Resources 1 Sponsor health fairs and education. Focus on special populations (ethnic, cultural, etc.). Take Control of Diabetes Manual, Centers for Disease Control and Prevention for Training Community Health Workers (Spanish) 2 Provide education to people at shelters and soup kitchens about diabetes, diet, exercise, etc. www.cdc.gov/diabetes/pubs/pubs.htm 3 Work with churches or faith-based organizations or other groups where your patients naturally gather, for instance, barbershops and hair salons, Provide space for meeting, transportation for patients to get to meetings and appointments, provide screening for diabetes and hypertension, education, peer support groups, communication channels to patients and families, etc. 4 Recruit and train migrant/homeless community health workers (CHWs) to assist in education and screening outreach programs. 5 Recruit and train CHWs to link patients and providers (e.g., chart flagging, lab/referrals, outreach, education, and transportation). 6 Have CHWs assist during support group meetings (e.g., providing testimonials or helping with food demonstrations). 7 Have a school health fair for primary prevention and to teach kids what problems their parents with diabetes may have. Children can be very effective communicators for effecting patient behavior change. Remember the patient who decides to quit after his child says, “Please stop smoking. I don’t want you to die.” Diabetes and Homelessness: Overcoming Barriers to Care, Manual www.nhchc.org/hot.html#diab.hot Tips Note that the American Diabetes Association 2001 clinical practice guidelines do not recommend community screening. Fingerstick screening at health fairs should be minimized. Healthy lifestyle education and prevention activities like foot screening for diabetics may be a better use of resources. Some successful health fairs have included educational offerings for providers (first two hours are provider in-service with outside speakers, followed by a public event with outside speakers addressing patients). Be sensitive to “turf” issues to maximize successful partnerships. Obtain support through Diabetes Control Program (DCP) funding sources. See “Care Model Changes for Specific Populations” in this manual for ideas relating to homeless/migrant populations. DIABETES TRAINING MANUAL 56 Community ➤Provide a list of community resources to patients, families, and staff. Steps Tools and Resources Tips 1 Identify existing lists of resources. 2 List the shopping malls that open early (and their hours) to accommodate walkers. Find out whether there is a shuttle or mall security available to safely escort walkers to the bus stop. 3 Assign a staff member or volunteer to collate lists, update information, and review for accuracy. Collect contact information and guidelines for program use. Create a notebook or computer database of resources. Contact local Senior Information and Assistance Program (federally mandated program) to avoid duplication of effort while building the resource guide. Look in phone book for Senior Information and Assistance—every community has this resource. 4 Check first to see if another community agency has already developed a resource guide, such as the Chamber of Commerce list of organizations. Update information routinely. DIABETES TRAINING MANUAL 57 Diabetes Care Model: Changes for Specific Populations The Care Model has been found useful in a wide range of settings for different populations. Teams working with unique groups may find that the emphasis on some model elements require greater emphasis than others. For example, self-management is very important for migrant populations who may seek health care in several geographic areas, while community linkages are crucial when working with homeless populations. In some cases, adaptation of key changes will be necessary. For example, pictorial educational information will be helpful for populations with low literacy. Self-Management The following ideas from other community health centers with experience applying the Care Model in a wide variety of settings may be helpful to you. ➤ Translate/adapt recipes. ➤ Address mobility in self-management issues. ➤ Use Track II, encouraging patients to bear responsibility for their own care and follow-up. ➤ Provide a cassette tape of patient education/provider instructions for mobile patients to listen to when traveling. ➤ Promote patient-led support groups. ➤ Offer evening, self-management clinics after work hours. ➤ Promote Track II participation and portable record carrying. ➤ Provide self-management goal setting that is culturally specific and includes family (e.g., how to choose food in a camp or shelter setting, how to obtain medication refills in a new site, etc.). ➤ Address occupational needs, such as self-management in the fields, foot care in the fields or on the street, snacks in the shelter, etc. ➤ Provide information on best choices from fast food restaurants. ➤ Use low-literacy tools for goal setting. ➤ Assess literacy level of all patient education materials and revise as needed. ➤ Provide glucometer and medication training, using low literacy techniques. DIABETES TRAINING MANUAL 58 Care Model: Changes for Specific Populations (continued) Decision Support Clinical Information System Delivery System Design ➤ Videotape preventive care instructions and play at all sites. ➤ Create flow sheets/portable records for migrant workers to take from center to center. ➤ Provide after-hours clinics at the centers. ➤ Offer provider education and updates on the special needs of farm workers through meetings, MCN, literature review, and web-based learning. ➤ Include migrant population in the registry. ➤ Take medical and dental care to the people (the farms, the camps, the shelters). ➤ Enroll migrant and homeless in Track II, the national tracking and referral project for migrating patients with diabetes. If you need information on Track II, you may call Carmel Drewes at MCN: 512-327-2017 or by email: [email protected]. ➤ Work with local migrant health centers (MHC) to identify common patients and develop a referral process and information transfer between the CHC and MHC. Consider sharing of services, e.g., in linked sites, one could do dental and the other could do eye care. ➤ Provide a tool for patients to track their yearly care needs. ➤ Train patients and providers on use of Track II. ➤ Develop communication between clinic sites that routinely share patients. ➤ Provide group visits in all locales. ➤ Follow special population data and be proactive about what you want to know from your data. ➤ Provide information system support from the main health center if the homeless or migrant site is small or rural. ➤ Provide shower facilities for patients in order to assist with personal care and promote attendance. ➤ Include oral health in all care visits for special populations. ➤ Incorporate Track II into routine service provision. ➤ Offer walk-in or same-day appointments for preventive and chronic care needs. ➤ If possible, offer low-sugar, low-fat snacks as an incentive to come to clinic, and to show an example of healthful food choices. ➤ Provide after-hours clinics at the centers. ➤ Take medical and dental care to the people (the farms, the camps, the shelters). DIABETES TRAINING MANUAL 59 Care Model: Changes for Specific Populations (continued) Organization of Health Care Community ➤ Use staff who are native speakers and promote language competency in staff. ➤ Identify community leaders who will serve as champions in the community. ➤ Provide resources for training opportunities for language development and local literacy promotion programs for the patients in the community. ➤ Have focus groups from the community help select teaching tools appropriate for the population. ➤ Collaborate with local hospitals, medical equipment suppliers, and specialty care providers to provide camp/shelter/motel on-site services and products. ➤ Adapt center hours to accommodate farm labor schedules. ➤ Consider off-site care delivery in the farm or camp setting. ➤ Provide child care during classes. ➤ Provide transportation to classes. ➤ Network with Migrant Head Start and Migrant Education Programs to collaborate in identifying and caring for migrant families. ➤ Provide community health worker training for outreach and education (promotoras). ➤ Use natural leaders on the health care team. ➤ Supply vouchers for dental, eye, and foot care. ➤ Coordinate diabetes education and screening for patients with kindergarten and school screenings for children. ➤ Have adult flu and Pneumovax available at pediatric immunization clinics. ➤ Have health fairs especially oriented to migrant/homeless populations. ➤ Find out the interests of faith-based and civic groups in the community and look for ways to join them in health promotion to migrant and homeless populations. ➤ Collaborate with area faith communities to enhance care provision. ➤ Explore glucometer and medication vouchers. ➤ Utilize Americorps volunteers. ➤ Link with medical school volunteers. ➤ Start a community sock-donation program. ➤ Collaborate with the local soup kitchen in nutrition education and meal planning. DIABETES TRAINING MANUAL 60 Diabetes Improvement Model The Improvement Model consists of three fundamental questions and a Plan-Do-Study-Act cycle to test and implement changes in real work settings. What are we trying to accomplish? Aims How will we know that a change is an improvement? Measures What changes can we make that will result in improvement? Changes ACT PLAN STUDY DO *The Improvement Model was developed by Associates in Process Improvement. DIABETES TRAINING MANUAL 61 Setting an Aim An aim is an explicit statement summarizing what your organization hopes to achieve. It helps to focus on specific actions to implement the Care Model, and to define which patients and providers will participate. Your aim statement should also be time-specific and measurable. The aim and selected measures should be “stretch goals,” not achievable in the current system of care. The aim should incorporate various components of the Care Model and emphasize that system redesign will be taking place. Example: We will redesign the office practice so that, within nine months, more than 70% of the patients with diabetes will have their last blood pressure below 140/90 and the average HbA1c will drop to below 8.0 by implementing the components of the Care Model. In setting your team’s aim, be sure to do the following: ➤ Involve the organization’s senior leaders. What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Leadership must align the aim with the strategic goals of the organization. ➤ Base the aim on both data and organizational needs. Examine data within your organization to help guide the establishment of an appropriate aim. Refer to the measurement section, and focus on issues that matter to the organization. ➤ State the aim clearly and use numerical goals. ACT PLAN STUDY DO Teams make better progress when they have unambiguous, specific goals. Setting numeric targets clarifies the aim, helps people focus for change, and directs measurement. For example, an aim to “increase the percentage of patients with self-management goals by 50%” will be more effective than an aim to “improve patient self-management practices.” ➤ Include appropriate guidance on approaches and methods. Describe the practice (office, clinic, practice team, etc.) and the patient population that will be the focus of this aim. Include specific strategies that the organization intends to follow. Guidance To augment the specific aim statement, the team may want to provide additional descriptive criteria. This is often referred to as “guidance” to the aim. Example: Our health center will develop and maintain a registry of all 250 of our patients with diabetes. We will focus initially on patient self-management methods and delivery system design. Two of the four physicians will be involved in the process at first. Once the changes have been implemented, the other two physicians and their panels will be included. DIABETES TRAINING MANUAL 62 Setting an Aim Patients with Diabetes: Population of Focus A Definition The Care Model is population-based. Population-based care is the process of identifying health problems within a specific population of patients, defining and assuring evidence-based interventions for members of that population, and regularly monitoring progress and scientific literature to keep interventions state-of-the-art. To identify the patient population, the team needs to be able to access data that can distinguish populations with different health problems. ICD 9 or CPT codes from billing data are the most common source for making these distinctions. The ability to tie billing codes to individual patients allows you to generate lists to contact and track patients for delivery of proven interventions, and to monitor their progress over time. Patient lists (or registries, as they are commonly called) can vary in complexity from manually maintained spreadsheets that contain the patients’ names and contact information (at a minimum) to an on-line software system that provides data query capabilities and care planning. Many health centers provide care to hundreds, or even thousands, of patients with diabetes. Similarly, many centers have multiple sites and providers. It is not reasonable to expect that care for all patients can be significantly redesigned at one time. It is strongly recommended that a team pick a sub-group (or sub-population) of patients with diabetes to be the focus of the change in practice. There are two criteria for selecting this sub-population (which we will refer to as “Population of Focus,” or POF). ➤ The total size of the population should be between 100 and 300 patients. ➤ The patients should be selected based on either clinic or provider, or both. For example, if at one clinic there are two providers with approximately 160 patients with diabetes, your Population of Focus could be all patients of both providers seen at this clinic. Note that the selection of the population of focus should not be based on risk levels or any demographic factors (only by provider and/or clinic). Pick the population of focus wisely. Pick the providers and clinics where the changes are most likely to be embraced. The following definition is used to identify patients with diabetes: “Patients with diabetes (Type 1 and Type 2), 18 to 75 years old, who were continuously enrolled during the year, and who have at least one visit to the clinic within the past calendar year are considered clinic patients unless there is documentation that the patient has transferred to another practice or has moved from the area.” In addition, clinics with managed care plans should try to include patients with diabetes who have no documented medical visit to the clinic, and who have been assigned to the clinic for 12 months, with no more than a 45-day drop in coverage. Once you have selected the population of focus, your team will concentrate improvement efforts on that group of patients. This does not mean that changes that are found to be effective with the population of focus cannot be spread to other clinics or providers. It only means that the initial effort and measurement will be directed toward this group. Example of Population of Focus (POF): Initially, we will focus on the patients of two of the four providers (Smith and Jones) at the Best Clinic site. This includes approximately 250 patients with diabetes, all of whom were seen at the clinic in 2001. DIABETES TRAINING MANUAL 63 ➤ For the current national measures, visit the Health Disparities Collaboratives website at www.healthdisparities.net Establishing Measures Related to Your Aim The Why, What, and How Much of Measurement Your health center’s goal is to improve care for people with diabetes, not to design a perfect measurement system. But measurement will play an important role in your efforts to improve care. Measurement will help you evaluate the impact of changes you make to improve the delivery of care to the population of persons with diabetes. Always remember that measurement should be designed to accelerate improvement, not slow it down. Your team needs just enough measurement to be convinced that the changes you are making are leading to improvement, and no more. Guidelines for Getting Started ➤ Plot data over time. What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Improvement in care of patients with chronic conditions will require continuously testing and implementing changes. Most of the information about performance of your system and how it has improved can be learned by observing trends and patterns in simple run charts (time series plots) of key measures directly related to your aim. ACT PLAN STUDY DO ➤ Focus on measures directly related to your aim. Measures that can be used to evaluate performance of the system relative to your team’s aim should be maintained on a regular basis. You may also want to use balancing measures (measures that track the effect that changes in one part of a system have on other parts of the system). ➤ Use the registry as the basis for your measures. The registry is a basic part of the clinical information system that will be part of your practice redesign. You can also use it to develop most of your key measures on the patient population of interest. ➤ Integrate measures into routine processes. Whenever possible, collect useful data as part of the normal performance of a work. Auditing charts is a very non-productive way to obtain data for measures. Update the registry after each patient visit. Develop simple data recording forms that are integrated into the patient visit. DIABETES TRAINING MANUAL 64 Testing and Implementing Changes Depending on their aim, teams choose promising changes from different elements of the Care Model and test them in their specific practice settings. Teams use Plan-Do-Study-Act (PDSA) cycles to test a change quickly on a small scale, see how it works, and refine the change as necessary before implementing it on a broader scale. The following example shows how Rocky Road Health Center developed and tested the use of an electronic registry to improve the measurement of HbA1c. What are we trying to accomplish? How will we know that a change is an improvement? PDSA Cycle Example: Step 4: Act Step 1: Plan After a team meeting with the executive director and the finance officer who also oversees the information system, the health center adapted a scannable flow sheet form they had learned about from the Midwest Clinicians Network. At the finance officer’s suggestion, they added patients’ insurance status to make sure eligible patients were enrolled in Medicaid or Medicare. To cut down on cycle time, the medical records of the diabetic patients were reviewed the night before to identify gaps and to pre-enter data. The team at the Rocky Road Health Center predicted that a registry of patients with diabetes would improve the measurement of HbA1c. Setting up this system took 3 weeks. During that time, the health center also established protocols for glucose measurements and ran a trial utilizing patient self-management for home glucose measurements. ACT Step 3: Study STUDY The time spent on completing the flow sheet increased from 1 minute to 2 minutes, and it took an additional 3 minutes to enter data into the registry. Waiting time for diabetic patients increased an average of 8 minutes. Of the patients with diabetes, only half had appropriate testing of HbA1c; but after the trial, all of these patients had current values. PLAN DOStep What changes can we make that will result in improvement? ACT PLAN STUDY DO 2: Do The registry was tested for 2 weeks with one enthusiastic volunteer nurse practitioner and her patients with diabetes. After the Diabetes flow sheet was revised to reflect the registry information, the collection went well. The health center could run additional PDSA cycles to test ways of using time even more effectively. In addition, the health center could run simultaneous PDSA cycles to test changes in patient self-management of glucose levels. DIABETES TRAINING MANUAL 65 Diabetes Bibliography* Clinical Management Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. NEJM. 1993;329:977-86. This is the definitive trial of tight glucose control in patients with Type I diabetes, demonstrating decreased complications with improved glucose control. Eakin EG, Bull SS, Glasgow RE, Mason M. Reaching those most in need: a review of diabetes self-management interventions in disadvantaged populations. Diabetes Metab Res Rev. 2002 Jan-Feb;18(1):26-35. *The diabetes bibliography was developed by Improving Chronic Illness Care, a National Program of the Robert Wood Johnson Foundation, and is available online at www.improvingchroniccare.org. Litzelman DK, Slemenda CW, Langefeld CD, et al. Reduction of lower extremity clinical abnormalities in patients with non-insulindependent diabetes mellitus. A randomized, controlled trial. Ann Intern Med. 1993 Jul 1;119(1):36-41. An intervention designed to reduce risk factors for lower-extremity amputations positively affected patient self-foot-care behavior, as well as the foot care given by health care providers, and reduced the prevalence of lower-extremity clinical disease in patients with diabetes. Sadur CN, Moline N, Costa M, Michalik D, Mendlowitz D, Roller S, Watson R, Swain BE, Selby JV, Javorski WC. Diabetes management in a health maintenance organization: Efficacy of care management using cluster visits. Department of Medicine, Kaiser Permanente Medical Care Program, Northern California, Pleasanton 94588, USA. Diabetes Care. United Kingdom Prospective Diabetes Study Group. Cost effectiveness analysis of improved blood pressure control in hypertensive patients with type 2 diabetes: UKPDS 40. BMJ. 1998;317:720-26. The UKPDS is a landmark study demonstrating the effectiveness of improved glycemic control on decreasing complications of Type II diabetes. Additional studies in the same population underscore the importance of maximizing blood pressure control. United Kingdom Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ. 1998;317:703-13. United Kingdom Prospective Diabetes Study Group. Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. BMJ. 1998;317:713-20. United Kingdom Prospective Diabetes Study Group. UKPDS 28: A Randomized Trial of Efficacy of Early Addition of Metformin in Sulfonylurea-Treated Type 2 Diabetes. Diabetes Care. 1998;21(1):87-92. DIABETES TRAINING MANUAL 66 Bibliography: Diabetes (continued) Primary Care Interventions Aubert R, Herman W, Waters J, et al. A randomized controlled trial of nurse case management within an HMO to improve glycemic control in patients with diabetes. Ann Intern Med. 1998 Oct 15;129(8):605-12. This trial demonstrates the effective use of care managers within a primary care setting in achieving significant improvement in glycemic control. Beck A, Scott J, Williams P, et al. A randomized trial of group outpatient visits for chronically ill older HMO members: The cooperative health care clinic. JAGS. 1997;45:543-49. Evidence that group visits can provide clinical care and result in beneficial outcomes for patients and providers. Behavioral Medicine Symposium. HMO Practice. 1995;9. This issue is devoted to assisting primary care clinicians in caring for patients with behavioral problems. It includes brief descriptions of programs that work and how providers integrate behavioral techniques into their practice. Brown JE, Glasgow RE, Toobert DJ. Integrating dietary self-management counseling into the regular office visit. Practical Diabetol. 1996 Dec;16-22. Examines the successes, difficulties, and implications of integrating patient self-management support, particularly dietary self-care regimens, into primary-care office visits. Population-Based Care Glasgow RE, Boles SM, Calder D, Dreyer L, Bagdade J. Diabetes care practice in primary care: results from two samples and three guidelines. Diabetes Care. In press. A meta-analysis of adherence to guidelines and discussion of the need for alternative measurement approaches. Gohdes D, Rith-Najarian S, Acot K, Shields R. Improving diabetes care in the primary health setting: The Indian Health Service experience. Ann Intern Med. 1996 Jan 1;124(1 Pt 2):149-52. The Indian Health Service provides a model of using standards and feedback to improve care of patients with diabetes. Wasson J, Gaudette C, Whaley F, Sauvigne A, Baribeau P, Welch HG. Telephone care as a substitute for routine clinic follow-up. JAMA. 1992;267:1788-93. The first randomized clinical trial demonstrating cost savings and satisfactory care from substituting regularly scheduled, proactive phone calls for some clinic visits. Weinberger M, Kirkman MS, Samsa GP, et al. A nurse-coordinated intervention for primary care patients with non-insulin-dependent diabetes mellitus: impact on glycemic control and health-related quality of life. J Gen Intern Med. 1995;10:59-66. This study demonstrates a pragmatic, lowintensity adjunct to care delivered by physicians that improved glycemic control. Friedman NM, Gleeson JM, Kent MJ, Foris MF, Rodriguez DJ. Management of diabetes mellitus in the Lovelace Health Systems; EPISODES OF CARE program. Effective Clinical Practice. 1998;1:5-11. This article describes the comprehensive diabetes program used in a managed care setting that resulted in improved diabetes care. McCullouch DK, Price MJ, Hindmarsh M, Wagner EH. A population-based approach to diabetes management in a primary care setting: early results and lessons learned. Effective Clinical Practice. 1998 AugSep;1(1):12-22. Payne TH, Galvin MS, Taplin SH, Austin B, Savarino J, Wagner EH. Practicing populationbased care in an HMO: Evaluation after 18 months. HMO Practice. 1995;9:101-6. Describes the experience of one practice team in providing population-based care, demonstrating improved guideline implementation and screening compliance. Renders CM, Valk GD, Griffin S, Wagner EH, Eijk JThM van, Assendelft WJJ. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Review, The Cochrane Library, Issue 1, 2002. DIABETES TRAINING MANUAL 67 Bibliography: Diabetes (continued) Self-Management Vogt TM, Hollis JF, Lichtenstein E, Stevens VJ, Glasgow R, Whitlock E. The medical care system and prevention: the need for a new paradigm. HMO Practice. 1998; 12(1):5-13. Reviews the priorities, effective use of resources and barriers to action in the use of preventive services, with recommendations for changing the paradigm. Anderson RM, Funnell MM, Butler PM, Arnold MS, Fitzgerald JT, Feste CC. Patient empowerment. Results of a randomized controlled trial. Diabetes Care. 1995;18:943-49. This wait-listed trial of empowerment techniques for patients with diabetes demonstrated improved self-efficacy and blood glucose control favoring the intervention. Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med. 1997;127:1097-102. This review article with an extensive bibliography describes the elements of collaborative care. Anderson RM, Funnell MM, Arnold MS. Using the empowerment approach to help patients change behavior. In: Anderson B, and Rubin R, eds. Practical Psychology for Diabetes Clinicians. Alexandria, VA: American Diabetes Association; 1996. Based on sound principles of counseling and educational psychology, this chapter examines the roles of provider and patient based on the significant differences between the treatment of acute diseases and diabetes. Wagner EH. Population-based management of diabetes care. Patient Educ Couns. 1995;26:225-30. This article provides an overview of the steps involved in population-based care. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Mil Quarterly. 1996;74(4):511-44. Comprehensive discussion of the model for improving chronic illness care. Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4. This editorial introduces an entire issue devoted to chronic illness care and is the first article publishing the model for improvement of chronic illness. Glasgow RE, Toobert DJ, and Gillette CD. Psychosocial Barriers to Diabetes SelfManagement and Quality of Life. Diabetes Spectrum 2001 14: 33-41. Lorig KR, Sobel DS, Stewart AL, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing utilization and costs: A randomized trial. Med Care. 1999 Jan;37(1):5-14. Research basis for the Chronic Disease SelfManagement Program developed by the Stanford Patient Education Research Center. Glasgow RE, La Chance PA, Toobert DJ, Brown J, Hampson SE, Riddle MA. Long term effects and costs of brief behavioural dietary intervention for patients with diabetes delivered from the medical office. Patient Educ Couns. 1997;32:175-84. See Aubert above. This study evaluates the effectiveness of a single session intervention involving touchscreen computer-assisted assessment the provided feedback on key barriers to dietary self-management. DIABETES TRAINING MANUAL 68 Diabetes List of Tools and Resources Self-Management American Association of Diabetes Educators Diabetes Patient Questionnaire Self-Management Support Tool Diabetes Self-Management Goal Setting (English and Spanish) State-Based Diabetes Control Program Group Visit Agenda State Diabetes Control Programs www.aadenet.org American Diabetes Association www.diabetes.org Article on a motivational intervention to improve care in Type 2 diabetes fampract.oupjournals.org/cgi/reprint/15/3/229.pdf www.cdc.gov/diabetes/states/index.htm www.cdc.gov/diabetes/pubs/glance.htm#dcp Stoplight Tool for HbA1c and Blood Sugar Targets Bayer Institute for Health Care, Patient Communication Training Health Professional Training and Patient Education in Diabetes (University of Michigan Diabetes Education Center) www.bayerinstitute.org www.med.umich.edu/mdrtc Take Charge of Your Diabetes, for Patients Chronic Disease Self-Management Program (CDSMP) National Diabetes Education Program www.cdc.gov/diabetes/pubs/pdf/tctd.pdf www.stanford.edu/group/perc/cdsmp.html Dental Self-Management Tool www.cdc.gov/diabetes/projects/ndeps.htm Self-Management Checklist (to Enhance Your Self-Management) Turning Patient Education into Self-Management, Training Instructions for Providers Self-Management Coordination Matrix Diabetes Goal Contract (English and Spanish) DIABETES TRAINING MANUAL 69 Diabetes: List of Tools and Resources (continued) Decision Support 7 Principles for Controlling Your Diabetes for Life (English and Spanish) ndep.nih.gov/materials/puborder/ resource.htm#people Centre for Evidence-Based Medicine cebm.jr2.ox.ac.uk Clinical Evidence for Providers [email protected] or 877-485-8074 Cochrane Reviews www.cochrane.org/cochrane/revabstr/ mainindex.htm Control Your Diabetes. For Life. Tips for Feeling Better and Staying Healthy (English and Spanish) ndep.nih.gov/materials/puborder/ resource.htm#people Diabetes Care Chart Audit Fax-back Form Patient Guide for Diabetes Management Hemoglobin A1c and Blood Sugar Targets Patient Tips for Good Control (English and Spanish) If You Have Diabetes, Know Your Blood Sugar Numbers (English and Spanish) Take Care of Your Feet for a Lifetime (English and Spanish) ndep.nih.gov/materials/puborder/ resource.htm#people ndep.nih.gov/materials/puborder/ resource.htm#people Indian Health Service, Patient Education Materials Trip Database www.ihs.gov/medicalprograms/diabetes National Guideline Clearinghouse The Unit for Evidence-Based Practice and Policy www.guideline.gov www.ucl.ac.uk/openlearning/uebpp/uebpp.htm National Institute for Diabetes & Digestive & Kidney Disease Wallet Card www.niddk.nih.gov/health/diabetes/pubs/ complications/teeth/teeth.com Netting the Evidence Diabetes Flow Sheet www.shef.ac.uk/~scharr/ir/netting New Zealand Guidelines Group Diabetes Protocol Checklist www.nzgg.org.nz Evaluating a Guideline Patient education materials designed for the Native American audience, which may be useful for other populations Evidence-Based Health Care Guideline Implementation Study www.tripdatabase.com www.doh.wa.gov/ndep/wallet.htm Why Don’t Physicians Follow Clinical Practice Guidelines? A Framework for Improvement Michael D. Cabana; Cynthia S. Rand; Neil R. Powe; Albert W. Wu; Modena H. Wilson; Paul-André C. Abboud; Haya R. Rubin. JAMA. 1999;282:1458-1465. ndep.nih.gov/materials/puborder/ resource.htm#people www.qmnetwork.org DIABETES TRAINING MANUAL 70 Diabetes: List of Tools and Resources (continued) Clinical Information System Chart Abstraction Form Diabetes Care Chart Audit Registry Assessment Tool Computer Assessment Tool Electronic Registry Sample Registry Report Constructing a Registry Definition of Homelessness Health Care for the Homeless Clinicians’ Network 615-226-2292 [email protected] www.nhchc.org The Unit for Evidence-Based Practice Track II: National Tracking and Referral Project for Migrating Patients with Diabetes Migrant Clinicians Network www.migrantclinician.org DIABETES TRAINING MANUAL 71 Diabetes: List of Tools and Resources (continued) Delivery System Design Conducting a Continuing Care Clinic: Handbook for the Practice Team Credentialing of Promotoras fax: 956-447-0553 Diabetes Flow Sheet ETHNIC: A Framework for Culturally Competent Clinical Practice, Organization Assessment Form www.state.nj.us/health/bibs/education/ethnic.html “Feet Can Last a Lifetime” Kit (2000), National Diabetes Education Program (includes ready-to-use exam forms, patient education handouts, etc.) ndep.nih.gov/materials/pubs/feet/feet.htm Group Visit Starter Kit Standing Orders Training materials, e.g., Lower Extremity Amputation Prevention (LEAP) Program bphc.hrsa.gov/leap/ Planning Group Visits for High Risk Patients, American Academy of Family Physicians Words to the Wise, Bilingual Course for Diabetes Promotoras, New Mexico Department of Health Diabetes Control Programs www.aafp.org/fpm/20000600/33plan.html 505-827-2953 Sample Registry Report Organization of Health Care Business Case for Disease Management www.improvingchroniccare.org Care Model www.improvingchroniccare.org Changing Practice, Changing Lives: The Health Disparities Collaboratives, Training and Promotional Videos www.healthdisparities.net Improvement Model Health Disparities Collaboratives Train-theTrainer Manual for Health Centers DIABETES TRAINING MANUAL 72 Diabetes: List of Tools and Resources (continued) Community American Optometric Association, Optometry Referral and Follow-up 800-262-3947 Americorps www.americorps.org/ Bayer Corporation/Bayer Indigent Patient Program 800-998-9180 Bristol-Myers Squibb Patient Assistance Program 800-437-0994 Center for Disease Control and Prevention www.cdc.gov/diabetes. Culturally Appropriate Patient Education Materials, Office of Minority Health www.omhrc.gov/ Diabetes and Homelessness: Overcoming Barriers to Care, Manual www.nhchc.org/hot.html#diab.hot Diabetes Today National Training Center training and technical assistance on applying a community mobilization model, Diabetes Today www.diabetestodayntc.org/ Eli Lilly & Company/Lilly Cares 800-545-6962 Hoechst Marion Roussel, Inc./Indigent Patient Program 800-2114025 National Diabetes Education Program 800-438-5383 or ndep.nih.gov National Diabetes Education Program, Diabetes Community Partnership Guide, page 51, “Organizations Making a Difference with 18 Easy Ideas.” ndep.nih.gov/materials/pubs/communityguide/community-guide.htm National Eye Care Project Helpline, No-Cost Ophthalmology Exam NovoNordisk Pharmaceuticals Inc/ Indigent Program 800-727-6500 PCA Directory Listing Pfizer Inc/Pfizer Prescription Assistance State Based Programs to Reduce the Burden of Diabetes Summit Health Institute for Research and Education (SHIRE), faith-based relationships 301-559-4400 Take Control of Diabetes Manual, Centers for Disease Control and Prevention for Training Community Health Workers (Spanish) www.cdc.gov/diabetes/pubs/pubs.htm Translation for Educational Materials: www.freetranslations.com www.systranet.com 1-800-222-EYES. 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